Healthcare Provider Details

I. General information

NPI: 1154619138
Provider Name (Legal Business Name): JOHN DAVIS HERRICK LADC, LCPC, CCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 07/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DELTA DR
WESTBROOK ME
04092-4745
US

IV. Provider business mailing address

1 DELTA DR
WESTBROOK ME
04092-4745
US

V. Phone/Fax

Practice location:
  • Phone: 207-856-7227
  • Fax: 207-856-2112
Mailing address:
  • Phone: 207-856-7227
  • Fax: 207-856-2112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLC2592
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: