Provider Demographics
NPI:1740792340
Name:ROBICHAUD, JEREMY THOMAS (LCSW)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:THOMAS
Last Name:ROBICHAUD
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 1:268 STILLWATER AVE
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3945
Mailing Address - Country:US
Mailing Address - Phone:207-973-6100
Mailing Address - Fax:
Practice Address - Street 1:100 S JUNIPER ST FL 3
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-1316
Practice Address - Country:US
Practice Address - Phone:267-999-9534
Practice Address - Fax:833-613-2680
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-04
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0233451041C0700X
NJ44SC061893001041C0700X
MELC187031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME4033201519Medicaid