Provider Demographics
NPI:1811051741
Name:BEALE, THOMAS JOHN (LCSW)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOHN
Last Name:BEALE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 425
Mailing Address - Street 2:42 CEDAR ST
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-0425
Mailing Address - Country:US
Mailing Address - Phone:207-947-0366
Mailing Address - Fax:
Practice Address - Street 1:42 CEDAR ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04402-0425
Practice Address - Country:US
Practice Address - Phone:207-947-0366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC43371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM6078Medicare ID - Type UnspecifiedMEDICARE LEGACY NUMBER