Provider Demographics
NPI:1265558522
Name:PITKIN, MARY GRAY (LCPC)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:GRAY
Last Name:PITKIN
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:PO BOX 1055
Mailing Address - Street 2:
Mailing Address - City:DAMARISCOTTA
Mailing Address - State:ME
Mailing Address - Zip Code:04543-1055
Mailing Address - Country:US
Mailing Address - Phone:207-563-5388
Mailing Address - Fax:
Practice Address - Street 1:27 RIVER RD
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:ME
Practice Address - Zip Code:04553-3845
Practice Address - Country:US
Practice Address - Phone:207-563-5388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC2134101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME048031OtherANTHEM BLUE CROSS
ME489OtherPROTEA #