MEDICARE: CHRISTY L. DERRAH LADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	LC3866	ME

General Provider Information

NPI Number	:	1851503395
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTY L. DERRAH LADC

Provider Business Mailing Address
First Line	:	382 MAIN STREET
Second Line	:
City	:	LIMESTONE
State	:	ME
Zip	:	04750
Country	:	US
Telephone Number	:	207-325-4727
Fax Number	:	207-325-4727

Provider Business Practice Location Address
First Line	:	382 MAIN STREET
Second Line	:
City	:	LIMESTONE
State	:	ME
Zip	:	04750
Country	:	US
Telephone Number	:	207-325-4727
Fax Number	:	207-325-4727

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	07/08/2007

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