Provider Demographics
NPI:1235149089
Name:O'TOOLE, RICHARD JOHN (LCSW)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOHN
Last Name:O'TOOLE
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 1:216 VAUGHAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3204
Mailing Address - Country:US
Mailing Address - Phone:207-662-2221
Mailing Address - Fax:207-662-3262
Practice Address - Street 1:216 VAUGHAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3204
Practice Address - Country:US
Practice Address - Phone:207-662-2221
Practice Address - Fax:207-662-3262
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC21381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM6905Medicare ID - Type Unspecified
MEMM690501Medicare PIN