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General NPI Number Information
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NPI Number | 1437296340
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Entity Type | Individual
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Provider Name | MICHAEL JOHN DEMATTEO I LCSW
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Gender | Male
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Dates
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Enumeration Date | 01/31/2007
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Last Update Date | 07/02/2019
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Provider Practice Location Address
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Address Line | 6 STATE ST
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City | BANGOR
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State | ME
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Zip | 04401-5112
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Country | US
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Telephone | 207-942-1944
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Fax | 207-942-1944
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Provider Business Mailing Address
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Address Line | 64 CHURCH STREET, OFFICE 1A
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City | ELLSWORTH
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State | ME
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Zip | 04605
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Country | US
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Telephone | 207-664-6061
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Fax | 207-664-6051
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LC5117
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License Number State | ME
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