Provider Demographics
NPI:1689004269
Name:RICHARDSON, MISTY RENEE (LCSW)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:RENEE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:RENEE
Other - Last Name:FILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:268 STILLWATER AVE
Mailing Address - Street 2:PO BOX 422
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3945
Mailing Address - Country:US
Mailing Address - Phone:207-973-9548
Mailing Address - Fax:207-973-6437
Practice Address - Street 1:268 STILLWATER AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3945
Practice Address - Country:US
Practice Address - Phone:207-973-9548
Practice Address - Fax:207-973-6437
Is Sole Proprietor?:No
Enumeration Date:2013-11-19
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC145161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical