Healthcare Provider Details

I. General information

NPI: 1750618781
Provider Name (Legal Business Name): KAREN MARIE GUDROE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAREN MARIE DELUCA LSW

II. Dates (important events)

Enumeration Date: 11/12/2009
Last Update Date: 11/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 WEST MAIN STREET
DOVER FOXCROFT ME
04426-0287
US

IV. Provider business mailing address

21 MAIN STREET SUITE 301
BANGOR ME
04401-6359
US

V. Phone/Fax

Practice location:
  • Phone: 207-941-8727
  • Fax: 207-992-2784
Mailing address:
  • Phone: 207-941-8727
  • Fax: 207-992-2784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC6799
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: