Provider Demographics
NPI:1619987435
Name:STICKNEY, SUSAN S (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:S
Last Name:STICKNEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1397 ROYALSBOROUGH RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04222-5231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-3113
Practice Address - Country:US
Practice Address - Phone:207-333-0476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC130271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME244250099Medicaid