1063549772 NPI number — MRS. REBECCA ERDE CLARK LMFT-C

Table of content: MRS. REBECCA ERDE CLARK LMFT-C (NPI 1063549772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063549772 NPI number — MRS. REBECCA ERDE CLARK LMFT-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
REBECCA
Provider Middle Name:
ERDE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMFT-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ERDE
Provider Other First Name:
REBECCA
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.S.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063549772
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 297
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWCASTLE
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04553-0297
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-563-3366
Provider Business Mailing Address Fax Number:
207-563-3393

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
80 RIVER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWCASTLE
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04553-3838
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-563-3366
Provider Business Practice Location Address Fax Number:
207-563-3393
Provider Enumeration Date:
02/28/2007

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: 106H00000X , with the licence number:  XM2762 , 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)





Copyright © 2007-2025 www.npivalidator.com