1760463871 NPI number — MR. ALFRED L BRODEUR LCSW

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760463871 NPI number — MR. ALFRED L BRODEUR LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRODEUR
Provider First Name:
ALFRED
Provider Middle Name:
L
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
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:
1760463871
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:
83 SIXTH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUBURN
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04210-6804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-784-3907
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
81 MAIN ST BOX 16
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04210-5883
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-777-1078
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/07/2005

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: 101YM0800X , with the licence number:  LC2135 , 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: 461514000 . This is a "MAGELLAN" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 017270 . This is a "BCBS" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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