Provider Demographics
NPI:1902026784
Name:HUMPHRIES, SUZANNE T (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:T
Last Name:HUMPHRIES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:SUE
Other - Middle Name:
Other - Last Name:HUMPHRIES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:8 OAKES MANOR RD
Mailing Address - Street 2:
Mailing Address - City:SANGERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04479-3101
Mailing Address - Country:US
Mailing Address - Phone:207-650-3987
Mailing Address - Fax:
Practice Address - Street 1:1093 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOVER FOXCROFT
Practice Address - State:ME
Practice Address - Zip Code:04426-3717
Practice Address - Country:US
Practice Address - Phone:207-564-8175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC67511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME256740099Medicaid
ME11803859OtherCAQH PROVIDER ID