Provider Demographics
NPI:1346454923
Name:MCBRADY, TIMOTHY MICHAEL (LPN, LADC, CCS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:MCBRADY
Suffix:
Gender:M
Credentials:LPN, LADC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:936 ROOSEVELT TRL
Mailing Address - Street 2:STE 14
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-5652
Mailing Address - Country:US
Mailing Address - Phone:207-893-0000
Mailing Address - Fax:
Practice Address - Street 1:2300 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-1908
Practice Address - Country:US
Practice Address - Phone:207-221-2292
Practice Address - Fax:207-221-2297
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC1323101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME251760099Medicaid