Provider Demographics
NPI:1477976397
Name:CROY, SHAYNE (LCSW)
Entity Type:Individual
Prefix:
First Name:SHAYNE
Middle Name:
Last Name:CROY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1081
Mailing Address - Street 2:
Mailing Address - City:ALFRED
Mailing Address - State:ME
Mailing Address - Zip Code:04002-1081
Mailing Address - Country:US
Mailing Address - Phone:072-502-5043
Mailing Address - Fax:
Practice Address - Street 1:469 MAIN ST STE 304
Practice Address - Street 2:
Practice Address - City:SPRINGVALE
Practice Address - State:ME
Practice Address - Zip Code:04083
Practice Address - Country:US
Practice Address - Phone:207-502-0056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-29
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC162961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1164484093Medicaid