1689825770 NPI number — MICHAEL J ANDRICK LCPC

Table of content: MICHAEL J ANDRICK LCPC (NPI 1689825770)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689825770 NPI number — MICHAEL J ANDRICK LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDRICK
Provider First Name:
MICHAEL
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689825770
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 SAM WENTWORTH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04027-3845
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-534-5927
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34 SUMMER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BANGOR
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04401-6446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-992-2636
Provider Business Practice Location Address Fax Number:
207-947-0435
Provider Enumeration Date:
10/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  XL3430 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 433038999 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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