Basic Information
| Provider Information | |||||||||
| NPI: | 1689885626 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOCTOMAH | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | KELLY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1013 HUDSON RD | ||||||||
| Address2: | |||||||||
| City: | GLENBURN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044011623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079453275 | ||||||||
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| Practice Location | |||||||||
| Address1: | 42 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044016433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079470366 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 11/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LC5210 | ME | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 325750099 | 05 | ME | MEDICAID |