Provider Demographics
NPI:1124165758
Name:STOWBRIDGE, MARC DONALD (LICSW)
Entity type:Individual
Prefix:MR
First Name:MARC
Middle Name:DONALD
Last Name:STOWBRIDGE
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 29
Mailing Address - Street 2:
Mailing Address - City:SOUTH TAMWORTH
Mailing Address - State:NH
Mailing Address - Zip Code:03883-0029
Mailing Address - Country:US
Mailing Address - Phone:603-323-7509
Mailing Address - Fax:
Practice Address - Street 1:829 BEARCAMP HWY.
Practice Address - Street 2:
Practice Address - City:SOUTH TAMWORTH
Practice Address - State:NH
Practice Address - Zip Code:03883-0029
Practice Address - Country:US
Practice Address - Phone:603-323-7509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH80001548Medicaid
NHRE1548Medicare ID - Type Unspecified