Healthcare Provider Details

I. General information

NPI: 1154760700
Provider Name (Legal Business Name): RANDY P SOUCY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2013
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CAMPUS AVE STE A&B
LEWISTON ME
04240
US

IV. Provider business mailing address

PO BOX 7291
LEWISTON ME
04243-7291
US

V. Phone/Fax

Practice location:
  • Phone: 207-755-3434
  • Fax: 207-755-3474
Mailing address:
  • Phone: 207-777-8950
  • Fax: 207-777-8800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC14696
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: