1053479915 NPI number — MR. FREEMAN R. COREY LCSW, LADC, CCS

Table of content: AHMED AL-MOUSAWI MD (NPI 1396040283)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053479915 NPI number — MR. FREEMAN R. COREY LCSW, LADC, CCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COREY
Provider First Name:
FREEMAN
Provider Middle Name:
R.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW, LADC, CCS
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:
1053479915
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
899 RIVERSIDE ST
Provider Second Line Business Mailing Address:
SUITE 240
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04103-1070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-871-1211
Provider Business Mailing Address Fax Number:
207-871-1232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 HATCH DR
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
CARIBOU
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04736-2159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-498-2400
Provider Business Practice Location Address Fax Number:
207-498-2400
Provider Enumeration Date:
12/04/2006

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: 101YA0400X , with the licence number:  LC901 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: CCS3537 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: LC3744 , 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: 098153 . This is a "ANTHEM BCBS NUMBER" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 431586399 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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