1619930112 NPI number — CYNTHIA L. DEMETRI LCPC LADC

Table of content: CYNTHIA L. DEMETRI LCPC LADC (NPI 1619930112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619930112 NPI number — CYNTHIA L. DEMETRI LCPC LADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEMETRI
Provider First Name:
CYNTHIA
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC LADC
Provider Gender Code:
F

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:
1619930112
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12 LAMBARD RD
Provider Second Line Business Mailing Address:
103
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04330-5954
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-368-2072
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
442 MOOSEHEAD TRAIL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWPORT
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04953-2123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-368-2072
Provider Business Practice Location Address Fax Number:
207-368-5290
Provider Enumeration Date:
04/07/2006

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: 101Y00000X , with the licence number:  CC882 , 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: 245730099 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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