Healthcare Provider Details

I. General information

NPI: 1073972535
Provider Name (Legal Business Name): MIKALA D BOUSQUET LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2016
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 BATH RD SWEETSER
BRUNSWICK ME
04011-2673
US

IV. Provider business mailing address

329 MAINE ST STE E101
BRUNSWICK ME
04011-3310
US

V. Phone/Fax

Practice location:
  • Phone: 800-434-3000
  • Fax:
Mailing address:
  • Phone: 207-373-2266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC18331
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: