Healthcare Provider Details

I. General information

NPI: 1053479915
Provider Name (Legal Business Name): FREEMAN R. COREY LCSW, LADC, CCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 02/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 HATCH DR SUITE 240
CARIBOU ME
04736-2159
US

IV. Provider business mailing address

899 RIVERSIDE ST SUITE 240
PORTLAND ME
04103-1070
US

V. Phone/Fax

Practice location:
  • Phone: 207-498-2400
  • Fax: 207-498-2400
Mailing address:
  • Phone: 207-871-1211
  • Fax: 207-871-1232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLC901
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCCS3537
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC3744
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: