Healthcare Provider Details

I. General information

NPI: 1902026784
Provider Name (Legal Business Name): SUZANNE T. HUMPHRIES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUE HUMPHRIES LCSW

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1093 W MAIN ST
DOVER FOXCROFT ME
04426-3717
US

IV. Provider business mailing address

8 OAKES MANOR RD
SANGERVILLE ME
04479-3101
US

V. Phone/Fax

Practice location:
  • Phone: 207-564-8175
  • Fax:
Mailing address:
  • Phone: 207-650-3987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC6751
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: