Healthcare Provider Details

I. General information

NPI: 1689885626
Provider Name (Legal Business Name): SUSAN KELLY SOCTOMAH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 CEDAR ST
BANGOR ME
04401-6433
US

IV. Provider business mailing address

1013 HUDSON RD
GLENBURN ME
04401-1623
US

V. Phone/Fax

Practice location:
  • Phone: 207-947-0366
  • Fax:
Mailing address:
  • Phone: 207-945-3275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC5210
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: