Provider Demographics
NPI:1801223573
Name:STOCKDALE, CARLA
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:STOCKDALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 MAIN ST
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:WINTHROP
Mailing Address - State:ME
Mailing Address - Zip Code:04364-1486
Mailing Address - Country:US
Mailing Address - Phone:207-377-2111
Mailing Address - Fax:
Practice Address - Street 1:149 MAIN ST
Practice Address - Street 2:SUITE 2A
Practice Address - City:WINTHROP
Practice Address - State:ME
Practice Address - Zip Code:04364-1486
Practice Address - Country:US
Practice Address - Phone:207-377-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC50221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical