Provider Demographics
NPI:1962888081
Name:ROLLINS, ERIC
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:ROLLINS
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 1:331 PINE ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-6308
Mailing Address - Country:US
Mailing Address - Phone:207-694-9043
Mailing Address - Fax:207-344-6177
Practice Address - Street 1:331 PINE ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-6308
Practice Address - Country:US
Practice Address - Phone:207-694-9043
Practice Address - Fax:207-344-6177
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-31
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY263696101YP2500X
MECC6174101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100672250Medicaid