Provider Demographics
NPI:1831324920
Name:LICHTMAN, JOHN DANIEL (LCSW)
Entity Type:Individual
Prefix:
First Name:JOHN DANIEL
Middle Name:
Last Name:LICHTMAN
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 1:343 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2006
Mailing Address - Country:US
Mailing Address - Phone:207-874-1030
Mailing Address - Fax:207-874-1009
Practice Address - Street 1:343 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2006
Practice Address - Country:US
Practice Address - Phone:207-874-1030
Practice Address - Fax:207-874-1009
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC129001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432972299Medicaid