Provider Demographics
NPI:1174832109
Name:GALLICE, DEVON TRACEY (LMSW-CC)
Entity Type:Individual
Prefix:MS
First Name:DEVON
Middle Name:TRACEY
Last Name:GALLICE
Suffix:
Gender:F
Credentials:LMSW-CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:899 RIVERSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1070
Mailing Address - Country:US
Mailing Address - Phone:207-871-1200
Mailing Address - Fax:207-871-1232
Practice Address - Street 1:58 TUGBOAT LANE
Practice Address - Street 2:
Practice Address - City:PHIPPSBURG
Practice Address - State:ME
Practice Address - Zip Code:04562
Practice Address - Country:US
Practice Address - Phone:207-389-1672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC127201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical