Provider Demographics
NPI:1750618781
Name:GUDROE, KAREN MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:MARIE
Last Name:GUDROE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:MARIE
Other - Last Name:DELUCA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:21 MAIN STREET
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6359
Mailing Address - Country:US
Mailing Address - Phone:207-941-8727
Mailing Address - Fax:207-992-2784
Practice Address - Street 1:1116 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:DOVER FOXCROFT
Practice Address - State:ME
Practice Address - Zip Code:04426-0287
Practice Address - Country:US
Practice Address - Phone:207-941-8727
Practice Address - Fax:207-992-2784
Is Sole Proprietor?:No
Enumeration Date:2009-11-12
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC67991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432015299Medicaid