Provider Demographics
NPI:1619998333
Name:GOSS, PRISCILLA M (LCSW, LADC, CCS)
Entity Type:Individual
Prefix:MS
First Name:PRISCILLA
Middle Name:M
Last Name:GOSS
Suffix:
Gender:F
Credentials:LCSW, LADC, CCS
Other - Prefix:MS
Other - First Name:PRISCILLA
Other - Middle Name:T
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW, LADC, CCS
Mailing Address - Street 1:25 HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401
Mailing Address - Country:US
Mailing Address - Phone:207-947-3594
Mailing Address - Fax:207-947-7108
Practice Address - Street 1:25 HUDSON ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-947-3594
Practice Address - Fax:207-947-7108
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC40721041C0700X
MELC750174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME424240099Medicaid
MEME7503OtherMEDICARE PTAN
ME424240099Medicaid