Provider Demographics
NPI:1356782502
Name:ST CYR, KELLY M (LPC-CC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:ST CYR
Suffix:
Gender:F
Credentials:LPC-CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04841-3304
Mailing Address - Country:US
Mailing Address - Phone:207-596-0359
Mailing Address - Fax:207-596-0350
Practice Address - Street 1:1 FRONT ST
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:ME
Practice Address - Zip Code:04530-2492
Practice Address - Country:US
Practice Address - Phone:207-442-8118
Practice Address - Fax:207-442-7692
Is Sole Proprietor?:No
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL40301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical