Healthcare Provider Details

I. General information

NPI: 1689039422
Provider Name (Legal Business Name): ANNIE DERTHICK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2015
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 HIGH ST
LEWISTON ME
04240
US

IV. Provider business mailing address

76 HIGH ST
LEWISTON ME
04240-7649
US

V. Phone/Fax

Practice location:
  • Phone: 207-795-2800
  • Fax:
Mailing address:
  • Phone: 207-795-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberPS1563
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number107779
License Number StateAK
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY900357
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: