Basic Information
| Provider Information | |||||||||
| NPI: | 1174832109 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GALLICE | ||||||||
| FirstName: | DEVON | ||||||||
| MiddleName: | TRACEY | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LMSW-CC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 899 RIVERSIDE ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041031070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078711200 | ||||||||
| FaxNumber: | 2078711232 | ||||||||
| Practice Location | |||||||||
| Address1: | 58 TUGBOAT LANE | ||||||||
| Address2: | |||||||||
| City: | PHIPPSBURG | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073891672 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2010 | ||||||||
| LastUpdateDate: | 06/07/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | MC12720 | ME | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.