Provider Demographics
NPI:1164533766
Name:MACLIN, CHARLES WAITE (MDIV)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:WAITE
Last Name:MACLIN
Suffix:
Gender:M
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1259
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104
Mailing Address - Country:US
Mailing Address - Phone:207-773-1314
Mailing Address - Fax:
Practice Address - Street 1:39 DEERING ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04104
Practice Address - Country:US
Practice Address - Phone:207-773-1314
Practice Address - Fax:207-871-0117
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELP584101YP1600X
MECC583101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MELP584OtherSTATE OF MAINE
MECC583OtherSTATE OF MAINE