MEDICARE: DIANE NAOMI PELLETIER LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LC6536	ME

General Provider Information

NPI Number	:	1881777191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE NAOMI PELLETIER LCSW

Provider Business Mailing Address
First Line	:	PO BOX 282
Second Line	:
City	:	SCARBOROUGH
State	:	ME
Zip	:	04070-0282
Country	:	US
Telephone Number	:	207-883-6745
Fax Number	:

Provider Business Practice Location Address
First Line	:	27 GORHAM RD STE 6
Second Line	:
City	:	SCARBOROUGH
State	:	ME
Zip	:	04074-8388
Country	:	US
Telephone Number	:	207-076-1408
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	01/18/2024

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