Provider Demographics
NPI:1578790499
Name:FRASER, WALLACE J JR (LCPC)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:J
Last Name:FRASER
Suffix:JR
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 WILBUR DR
Mailing Address - Street 2:
Mailing Address - City:HAMPDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04444-1420
Mailing Address - Country:US
Mailing Address - Phone:207-735-7136
Mailing Address - Fax:207-614-7141
Practice Address - Street 1:27 WILBUR DR
Practice Address - Street 2:
Practice Address - City:HAMPDEN
Practice Address - State:ME
Practice Address - Zip Code:04444-1420
Practice Address - Country:US
Practice Address - Phone:207-735-7136
Practice Address - Fax:207-433-1462
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-18
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC3848101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health