Provider Demographics
NPI:1700940798
Name:SMITH, DOUGLAS JAMES (LCPC)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:JAMES
Last Name:SMITH
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 COBBS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NEW GLOUCESTER
Mailing Address - State:ME
Mailing Address - Zip Code:04260-3834
Mailing Address - Country:US
Mailing Address - Phone:207-926-4151
Mailing Address - Fax:
Practice Address - Street 1:205 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-5712
Practice Address - Country:US
Practice Address - Phone:207-773-7993
Practice Address - Fax:207-773-5512
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME00974101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME047305OtherANTHEM