Provider Demographics
NPI:1275655706
Name:FRALICH, TERRY ALAN (LCPC)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:ALAN
Last Name:FRALICH
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 SMUTTY LN
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-9718
Mailing Address - Country:US
Mailing Address - Phone:207-294-3377
Mailing Address - Fax:207-294-3377
Practice Address - Street 1:129 SMUTTY LN
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-9718
Practice Address - Country:US
Practice Address - Phone:207-294-3377
Practice Address - Fax:207-294-3377
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC1769101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME042739OtherANTHEM