Healthcare Provider Details

I. General information

NPI: 1376773044
Provider Name (Legal Business Name): JOHN W REIDY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2009
Last Update Date: 07/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 GORDON FARMS RD
GORHAM ME
04038-2389
US

IV. Provider business mailing address

PO BOX 1360
WINDHAM ME
04062-1360
US

V. Phone/Fax

Practice location:
  • Phone: 207-893-0386
  • Fax: 207-893-2086
Mailing address:
  • Phone: 207-893-0386
  • Fax: 207-893-2086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC12053
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: