Basic Information
| Provider Information | |||||||||
| NPI: | 1700903804 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELQUIST | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 909 MIDDLE ST | ||||||||
| Address2: | |||||||||
| City: | BATH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 045302450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076155871 | ||||||||
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| Practice Location | |||||||||
| Address1: | 899 RIVERSIDE ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041031070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078711200 | ||||||||
| FaxNumber: | 2078711232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 05/03/2017 | ||||||||
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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 | 103TC0700X | PS1034 | ME | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.