Provider Demographics
NPI:1639254865
Name:ROY, STEPHEN GERARD (LCSW)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:GERARD
Last Name:ROY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 FEDERAL ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101
Mailing Address - Country:US
Mailing Address - Phone:207-774-6412
Mailing Address - Fax:207-772-7702
Practice Address - Street 1:69 FEDERAL ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101
Practice Address - Country:US
Practice Address - Phone:207-774-6412
Practice Address - Fax:207-772-7702
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC45041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMH8626Medicare ID - Type Unspecified