Provider Demographics
NPI:1083920169
Name:TRICKETT, HEATHER A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:A
Last Name:TRICKETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SOUTHBOROUGH DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6914
Mailing Address - Country:US
Mailing Address - Phone:207-661-2018
Mailing Address - Fax:207-661-2033
Practice Address - Street 1:165 LANCASTER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2406
Practice Address - Country:US
Practice Address - Phone:207-874-1030
Practice Address - Fax:207-874-1044
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-26
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC160081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400323534Medicare PIN