Healthcare Provider Details

I. General information

NPI: 1649370545
Provider Name (Legal Business Name): MARIE LOUISE DEXTER CLINICAL COUNSELOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 10/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 POND STREET
RANGELEY ME
04970-0157
US

IV. Provider business mailing address

12 POND STREET P.O. BOX 157
RANGELELY ME
04970-0157
US

V. Phone/Fax

Practice location:
  • Phone: 207-864-2670
  • Fax: 207-864-5600
Mailing address:
  • Phone: 207-864-2670
  • Fax: 207-864-5600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number169
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCC 3422
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: