Provider Demographics
NPI:1275956211
Name:SMITH, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 HATCH DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CARIBOU
Mailing Address - State:ME
Mailing Address - Zip Code:04736-2161
Mailing Address - Country:US
Mailing Address - Phone:207-764-6340
Mailing Address - Fax:207-768-6430
Practice Address - Street 1:43 HATCH DR
Practice Address - Street 2:SUITE 210
Practice Address - City:CARIBOU
Practice Address - State:ME
Practice Address - Zip Code:04736-2161
Practice Address - Country:US
Practice Address - Phone:207-764-6340
Practice Address - Fax:207-768-6430
Is Sole Proprietor?:No
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1275956211Medicaid