Provider Demographics
NPI:1053471995
Name:SIMPSON, SHANE SULLIVAN (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:SULLIVAN
Last Name:SIMPSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 INTERVALE RD
Mailing Address - Street 2:
Mailing Address - City:NEW GLOUCESTER
Mailing Address - State:ME
Mailing Address - Zip Code:04260-3812
Mailing Address - Country:US
Mailing Address - Phone:207-807-5610
Mailing Address - Fax:
Practice Address - Street 1:230 BARTLETT ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-6578
Practice Address - Country:US
Practice Address - Phone:207-783-4695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC86931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical