Provider Demographics
NPI:1548570989
Name:MOUTEVELIS-BURGESS, POLLY (LCPC, LMFT)
Entity Type:Individual
Prefix:DR
First Name:POLLY
Middle Name:
Last Name:MOUTEVELIS-BURGESS
Suffix:
Gender:F
Credentials:LCPC, LMFT
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 2354
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-2354
Mailing Address - Country:US
Mailing Address - Phone:207-990-5070
Mailing Address - Fax:207-581-3017
Practice Address - Street 1:106 PINE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5294
Practice Address - Country:US
Practice Address - Phone:207-990-5070
Practice Address - Fax:207-581-3017
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC284101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional