Provider Demographics
NPI:1407936669
Name:OSTHERR, MARY-ELLEN (MA LADC CCS)
Entity Type:Individual
Prefix:
First Name:MARY-ELLEN
Middle Name:
Last Name:OSTHERR
Suffix:
Gender:F
Credentials:MA LADC CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 HOSMER POND RD
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04843-4053
Mailing Address - Country:US
Mailing Address - Phone:207-841-6775
Mailing Address - Fax:207-236-8073
Practice Address - Street 1:17 MASONIC STREET
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841
Practice Address - Country:US
Practice Address - Phone:207-841-6775
Practice Address - Fax:207-236-8073
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC3421101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME104000000Medicaid