Provider Demographics
NPI:1770594681
Name:SMALL, MARY (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:ARMSTRONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:176 LIVERMORE FALLS RD
Mailing Address - Street 2:STE A
Mailing Address - City:FARMINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04938-6243
Mailing Address - Country:US
Mailing Address - Phone:207-512-4801
Mailing Address - Fax:207-778-4939
Practice Address - Street 1:176 LIVERMORE FALLS RD
Practice Address - Street 2:STE A
Practice Address - City:FARMINGTON
Practice Address - State:ME
Practice Address - Zip Code:04938-6243
Practice Address - Country:US
Practice Address - Phone:207-512-4801
Practice Address - Fax:207-778-4939
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2009-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC68461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431894599Medicaid
P28624Medicare UPIN
MEMM8798Medicare ID - Type Unspecified