Provider Demographics
NPI:1912329863
Name:FRAIZE, DARRELL
Entity type:Individual
Prefix:
First Name:DARRELL
Middle Name:
Last Name:FRAIZE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 HOYTS RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04009-1239
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 HOYTS RIDGE RD
Practice Address - Street 2:
Practice Address - City:BRIDGTON
Practice Address - State:ME
Practice Address - Zip Code:04009-1239
Practice Address - Country:US
Practice Address - Phone:207-647-5629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC3515101YA0400X
MECC3575101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)