Healthcare Provider Details

I. General information

NPI: 1912199951
Provider Name (Legal Business Name): SUSAN E BAKALEY-MARSHALL LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 05/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 HALLDALE RD
MONTVILLE ME
04941-4066
US

IV. Provider business mailing address

253 HALLDALE RD
MONTVILLE ME
04941-4066
US

V. Phone/Fax

Practice location:
  • Phone: 207-589-3063
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC256
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: