Provider Demographics
NPI:1275810475
Name:MCGOWAN, BROC A (LMSW CC)
Entity Type:Individual
Prefix:
First Name:BROC
Middle Name:A
Last Name:MCGOWAN
Suffix:
Gender:M
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 1:572 BANGOR RD
Mailing Address - Street 2:
Mailing Address - City:DOVER FOXCROFT
Mailing Address - State:ME
Mailing Address - Zip Code:04426-3373
Mailing Address - Country:US
Mailing Address - Phone:207-564-2464
Mailing Address - Fax:207-564-2404
Practice Address - Street 1:148 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DOVER FOXCROFT
Practice Address - State:ME
Practice Address - Zip Code:04426-1305
Practice Address - Country:US
Practice Address - Phone:207-564-2464
Practice Address - Fax:207-564-2404
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC131941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical