Basic Information
| Provider Information | |||||||||
| NPI: | 1265444004 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARABALLO | ||||||||
| FirstName: | HECTOR | ||||||||
| MiddleName: | RAFAEL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 67 EUSTIS PKWY | ||||||||
| Address2: | |||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049015173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078732136 | ||||||||
| FaxNumber: | 2078724522 | ||||||||
| Practice Location | |||||||||
| Address1: | 67 EUSTIS PKWY | ||||||||
| Address2: | |||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049015173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078732136 | ||||||||
| FaxNumber: | 2078724522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 03/17/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | CC3373 | ME | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 432149999 | 05 | ME | MEDICAID |