Doctor Name: | JAYNE BOULOS |
NPI Number: | 1861892671 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | LPE |
License Number: | PE 1398 |
Business Practice Address: | 60 Edgewood Rd Cape Elizabeth, ME - 041071277 |
Business Phone Number: | 2077675417 |
Business Fax Number: | |
Mailing Address: | 60 Edgewood Rd, CAPE ELIZABETH |
State: | ME |
Postal Code: | 041071277 |
Phone Number: | 2077675417 |
Fax Number: | |
NPI Enumeration Date: | 08/28/2014 |
NPI Last Update Date: | 08/28/2014 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103TS0200X |
License Number: | PE 1398 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | ME |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Psychologist |
Taxonomy Specialization: | School |
Taxonomy Definition: |