Provider Demographics
NPI:1598952913
Name:WAKELY, LINDA KEIL (PHD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:KEIL
Last Name:WAKELY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 STATE ST
Mailing Address - Street 2:SUITE 603
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5112
Mailing Address - Country:US
Mailing Address - Phone:207-942-8085
Mailing Address - Fax:207-942-5788
Practice Address - Street 1:6 STATE ST
Practice Address - Street 2:SUITE 603
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5112
Practice Address - Country:US
Practice Address - Phone:207-942-8085
Practice Address - Fax:207-942-5788
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-30
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS00519103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMM3603Medicare PIN