Basic Information
| Provider Information | |||||||||
| NPI: | 1053479915 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COREY | ||||||||
| FirstName: | FREEMAN | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW, LADC, CCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 899 RIVERSIDE ST | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041031070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078711211 | ||||||||
| FaxNumber: | 2078711232 | ||||||||
| Practice Location | |||||||||
| Address1: | 7 HATCH DR | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | CARIBOU | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047362159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074982400 | ||||||||
| FaxNumber: | 2074982400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 02/02/2016 | ||||||||
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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 | 101YA0400X | LC901 | ME | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | CCS3537 | ME | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | LC3744 | ME | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 098153 | 01 | ME | ANTHEM BCBS NUMBER | OTHER | 431586399 | 05 | ME | MEDICAID |