Healthcare Provider Details

I. General information

NPI: 1255453361
Provider Name (Legal Business Name): RICHARD D. BISSELL JR. LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 CEDAR ST
BANGOR ME
04401-6433
US

IV. Provider business mailing address

223 CLARK HILL RD
HOLDEN ME
04429-7250
US

V. Phone/Fax

Practice location:
  • Phone: 207-947-0366
  • Fax: 207-942-4350
Mailing address:
  • Phone: 207-843-0510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC10001
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: