Provider Demographics
NPI:1568591709
Name:MYTAR, MARC (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:
Last Name:MYTAR
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 MYTAR LN
Mailing Address - Street 2:
Mailing Address - City:SURRY
Mailing Address - State:ME
Mailing Address - Zip Code:04684-3609
Mailing Address - Country:US
Mailing Address - Phone:207-667-2095
Mailing Address - Fax:
Practice Address - Street 1:64 CHURCH ST
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-1658
Practice Address - Country:US
Practice Address - Phone:207-667-2095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0429103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME0429OtherME PSYCHOLOGY LICENSE