Healthcare Provider Details

I. General information

NPI: 1194637348
Provider Name (Legal Business Name): MARISSA BROUETTE-KEISER LCPCCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 HATCH DR STE 310
CARIBOU ME
04736-2039
US

IV. Provider business mailing address

180 ACADEMY ST STE 3
PRESQUE ISLE ME
04769-3183
US

V. Phone/Fax

Practice location:
  • Phone: 207-493-3361
  • Fax:
Mailing address:
  • Phone: 207-554-2352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberXL8952
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: