Provider Demographics
NPI:1679083604
Name:MASTRORIO, JAIME (LCSW)
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:MASTRORIO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 CLARK ST APT B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-4112
Mailing Address - Country:US
Mailing Address - Phone:508-243-3580
Mailing Address - Fax:
Practice Address - Street 1:32 CLARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-4100
Practice Address - Country:US
Practice Address - Phone:508-243-3580
Practice Address - Fax:207-878-2259
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-04
Last Update Date:2022-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC183781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMC16717OtherLICENSE MAINE
MELC18378OtherLICENSE MAINE