Healthcare Provider Details

I. General information

NPI: 1982750774
Provider Name (Legal Business Name): TERI LEASURE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 08/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 BARIBEAU DR SUITE 8
BRUNSWICK ME
04011-3230
US

IV. Provider business mailing address

66 BARIBEAU DR SUITE 8
BRUNSWICK ME
04011-3230
US

V. Phone/Fax

Practice location:
  • Phone: 207-373-6971
  • Fax: 207-373-6959
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC5720
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: