Provider Demographics
NPI:1629530530
Name:FRASER CLINICAL CONSULTATION SERVICES
Entity Type:Organization
Organization Name:FRASER CLINICAL CONSULTATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:J
Authorized Official - Last Name:FRASER
Authorized Official - Suffix:JR
Authorized Official - Credentials:LCPC
Authorized Official - Phone:207-735-7136
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-01
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health