Provider Demographics
NPI:1225156813
Name:ROY, MARY ANNE NICOLE (PSYD)
Entity type:Individual
Prefix:
First Name:MARY ANNE
Middle Name:NICOLE
Last Name:ROY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 PEARL ST STE 326
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4167
Mailing Address - Country:US
Mailing Address - Phone:207-773-9931
Mailing Address - Fax:
Practice Address - Street 1:66 PEARL ST STE 326
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4167
Practice Address - Country:US
Practice Address - Phone:207-773-9931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1269103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432502899Medicaid
ME098304OtherANTHEM LEGACY NUMBER