Provider Demographics
NPI:1922017029
Name:QUIMBY, LUCY GARDNER (PHD)
Entity Type:Individual
Prefix:
First Name:LUCY
Middle Name:GARDNER
Last Name:QUIMBY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 COLUMBIA ST
Mailing Address - Street 2:SUITE 32
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6346
Mailing Address - Country:US
Mailing Address - Phone:207-945-3675
Mailing Address - Fax:
Practice Address - Street 1:43 COLUMBIA ST
Practice Address - Street 2:SUITE 32
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6346
Practice Address - Country:US
Practice Address - Phone:207-945-3675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS750103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM4548Medicare ID - Type Unspecified