Healthcare Provider Details

I. General information

NPI: 1295895340
Provider Name (Legal Business Name): MARIANNE FRICKE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

268 STATE ST ROOM 2-4
BANGOR ME
04401-5417
US

IV. Provider business mailing address

268 STATE ST ROOM 2-4
BANGOR ME
04401-5417
US

V. Phone/Fax

Practice location:
  • Phone: 207-990-0188
  • Fax: 207-990-6604
Mailing address:
  • Phone: 207-990-0188
  • Fax: 207-990-6604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLC7263
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: