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General NPI Number Information
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NPI Number | 1568591709
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Entity Type | Individual
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Provider Name | MARC MYTAR PHD
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Gender | Male
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Dates
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Enumeration Date | 03/05/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 64 CHURCH ST
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City | ELLSWORTH
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State | ME
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Zip | 04605-1658
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Country | US
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Telephone | 207-667-2095
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Fax |
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Provider Business Mailing Address
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Address Line | 15 MYTAR LN
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City | SURRY
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State | ME
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Zip | 04684-3609
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Country | US
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Telephone | 207-667-2095
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Fax |
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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 | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 0429
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License Number State | ME
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