Provider Demographics
NPI:1811203185
Name:MCCARTNEY, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MCCARTNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:LAVOIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24 SPRINGER DR STE 202
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3655
Mailing Address - Country:US
Mailing Address - Phone:207-992-2535
Mailing Address - Fax:
Practice Address - Street 1:24 SPRINGER DR STE 202
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3655
Practice Address - Country:US
Practice Address - Phone:207-992-2535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC140881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME435945499OtherPROVIDER ENROLLMENT