Provider Demographics
NPI:1184665572
Name:FIDLER, LISA ANNE (LCSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:FIDLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 WALTER ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6232
Mailing Address - Country:US
Mailing Address - Phone:207-941-4321
Mailing Address - Fax:207-941-4207
Practice Address - Street 1:656 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5609
Practice Address - Country:US
Practice Address - Phone:207-941-4036
Practice Address - Fax:207-941-4062
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC104391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical