Provider Demographics
NPI:1053658294
Name:YERXA, NICOLETTE W (MHRT-CSP)
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:W
Last Name:YERXA
Suffix:
Gender:F
Credentials:MHRT-CSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 STACKPOLE DR
Mailing Address - Street 2:
Mailing Address - City:MACHIAS
Mailing Address - State:ME
Mailing Address - Zip Code:04654-7000
Mailing Address - Country:US
Mailing Address - Phone:207-255-0996
Mailing Address - Fax:207-255-8748
Practice Address - Street 1:1 STACKPOLE DR
Practice Address - Street 2:
Practice Address - City:MACHIAS
Practice Address - State:ME
Practice Address - Zip Code:04654-7000
Practice Address - Country:US
Practice Address - Phone:207-255-0996
Practice Address - Fax:207-255-8748
Is Sole Proprietor?:No
Enumeration Date:2013-01-08
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME010276859Medicaid