Healthcare Provider Details

I. General information

NPI: 1427539378
Provider Name (Legal Business Name): KELLY H BICKMORE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2018
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 FOREST AVE STE 207
PORTLAND ME
04103-3336
US

IV. Provider business mailing address

980 FOREST AVE STE 207
PORTLAND ME
04103-3336
US

V. Phone/Fax

Practice location:
  • Phone: 207-347-6106
  • Fax: 207-347-6113
Mailing address:
  • Phone: 207-347-6106
  • Fax: 207-347-6113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC6482
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: