Healthcare Provider Details

I. General information

NPI: 1780685511
Provider Name (Legal Business Name): MARK I HOLBROOK L.C.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 GIVEN SHIPYARD RD
BRUNSWICK ME
04011-3804
US

IV. Provider business mailing address

13 GURNET RD SUITE 130
BRUNSWICK ME
04011-2767
US

V. Phone/Fax

Practice location:
  • Phone: 207-373-1480
  • Fax:
Mailing address:
  • Phone: 207-373-1480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC 2358
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: