Healthcare Provider Details

I. General information

NPI: 1205835550
Provider Name (Legal Business Name): CAROL W IPPOLITI LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 RIVER ST
DOVER FOXCROFT ME
04426-1322
US

IV. Provider business mailing address

PO BOX 380
DOVER FOXCROFT ME
04426-0380
US

V. Phone/Fax

Practice location:
  • Phone: 207-564-7106
  • Fax: 207-564-0881
Mailing address:
  • Phone: 207-564-7106
  • Fax: 207-564-0881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC5292
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: