Basic Information
| Provider Information | |||||||||
| NPI: | 1003944752 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARKER | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 OSBORNE AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041064447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077768146 | ||||||||
| FaxNumber: | 2077792303 | ||||||||
| Practice Location | |||||||||
| Address1: | 854 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041062712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077768146 | ||||||||
| FaxNumber: | 2077992303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 07/10/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | MC9966 | ME | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 431883099 | 05 | ME | MEDICAID |