Provider Demographics
NPI:1134350234
Name:MOORE, MARY D (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:D
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:D
Other - Last Name:TRICHTINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1599
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1599
Mailing Address - Country:US
Mailing Address - Phone:207-945-5247
Mailing Address - Fax:207-947-0435
Practice Address - Street 1:1012 UNION ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3060
Practice Address - Country:US
Practice Address - Phone:207-945-5247
Practice Address - Fax:207-990-1248
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC1351101YA0400X
MELC12013101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432238199Medicaid