Provider Demographics
NPI:1689885626
Name:SOCTOMAH, SUSAN KELLY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:KELLY
Last Name:SOCTOMAH
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 1:1013 HUDSON RD
Mailing Address - Street 2:
Mailing Address - City:GLENBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04401-1623
Mailing Address - Country:US
Mailing Address - Phone:207-945-3275
Mailing Address - Fax:
Practice Address - Street 1:42 CEDAR ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6433
Practice Address - Country:US
Practice Address - Phone:207-947-0366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC52101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME325750099Medicaid