Healthcare Provider Details

I. General information

NPI: 1063110302
Provider Name (Legal Business Name): CRAIG J DEMERCHANT LMSW-CC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2023
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 SUMMIT AVE
BANGOR ME
04401-5631
US

IV. Provider business mailing address

63 SUMMIT AVE
BANGOR ME
04401-5631
US

V. Phone/Fax

Practice location:
  • Phone: 207-217-4781
  • Fax:
Mailing address:
  • Phone: 207-942-3799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberMC21294
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: