Provider Demographics
NPI:1912199951
Name:BAKALEY-MARSHALL, SUSAN E (LCPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:BAKALEY-MARSHALL
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 HALLDALE RD
Mailing Address - Street 2:
Mailing Address - City:MONTVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04941-4066
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:253 HALLDALE RD
Practice Address - Street 2:
Practice Address - City:MONTVILLE
Practice Address - State:ME
Practice Address - Zip Code:04941-4066
Practice Address - Country:US
Practice Address - Phone:207-589-3063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC256101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431547499Medicaid