Provider Demographics
NPI:1669563060
Name:WHITE, MARY T (MED, LPC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:WHITE
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 MAIN STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605-1941
Mailing Address - Country:US
Mailing Address - Phone:207-667-1153
Mailing Address - Fax:207-667-1153
Practice Address - Street 1:198 MAIN STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-1941
Practice Address - Country:US
Practice Address - Phone:207-667-1153
Practice Address - Fax:207-667-1153
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPC1124101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME$$$$$$$$$OtherSSN - SOLE PROPRIETORSHIP
ME7944152OtherAETNA PIN NUMBER
ME348180OtherTRICARE PIN NUMBER