Provider Demographics
NPI:1538749692
Name:HANNINGTON-BERUBE, THADIUS (LCPC-C)
Entity type:Individual
Prefix:
First Name:THADIUS
Middle Name:
Last Name:HANNINGTON-BERUBE
Suffix:
Gender:M
Credentials:LCPC-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5203
Mailing Address - Country:US
Mailing Address - Phone:207-956-5977
Mailing Address - Fax:
Practice Address - Street 1:77 BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5203
Practice Address - Country:US
Practice Address - Phone:207-956-5977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-13
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL5454101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health