Provider Demographics
NPI:1548675200
Name:PORTLAND DOULA COLLABORATIVE
Entity type:Organization
Organization Name:PORTLAND DOULA COLLABORATIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, LMT, CPMT, DOULA
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:LATENDRESSE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, CPMT
Authorized Official - Phone:207-632-1242
Mailing Address - Street 1:30 UPPER MAST LANDING RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-6417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 UPPER MAST LANDING RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-6417
Practice Address - Country:US
Practice Address - Phone:207-632-1242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-21
Last Update Date:2014-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
MEMT2239225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty