Provider Demographics
NPI:1700903804
Name:MELQUIST, MARY T (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:T
Last Name:MELQUIST
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:ME
Mailing Address - Zip Code:04530-2450
Mailing Address - Country:US
Mailing Address - Phone:207-615-5871
Mailing Address - Fax:
Practice Address - Street 1:899 RIVERSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-1070
Practice Address - Country:US
Practice Address - Phone:207-871-1200
Practice Address - Fax:207-871-1232
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1034103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical