Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YM0800X | Mental Health Counselor |
NPI | 1003220393 |
---|---|
Provider Name | Deric Flaherty |
First Address | Presque Isle, ME 04769-2817 |
Second Address | Presque Isle, ME 04769-2817 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/06/2014 |
Last Update Date | 17/06/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1003220393 | (05) | ME |