Provider Demographics
NPI:1609887512
Name:BELICOSE, RAYMOND MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:MICHAEL
Last Name:BELICOSE
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 1:28 ASHTON ST
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9434
Mailing Address - Country:US
Mailing Address - Phone:207-883-6975
Mailing Address - Fax:
Practice Address - Street 1:131 OCEAN ST
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3649
Practice Address - Country:US
Practice Address - Phone:207-409-3459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC95971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME048264OtherMMC PHO
ME048264OtherANTHEM BC/BS