Basic Information
| Provider Information | |||||||||
| NPI: | 1063549772 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | ERDE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ERDE | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.S. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 297 | ||||||||
| Address2: | |||||||||
| City: | NEWCASTLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 045530297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075633366 | ||||||||
| FaxNumber: | 2075633393 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 RIVER RD | ||||||||
| Address2: | |||||||||
| City: | NEWCASTLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 045533838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075633366 | ||||||||
| FaxNumber: | 2075633393 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | XM2762 | ME | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.