Healthcare Provider Details

I. General information

NPI: 1093044935
Provider Name (Legal Business Name): MRS. GRACE ELIZABETH LACOURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2009
Last Update Date: 12/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 OLD ALFRED RD
EAST WATERBORO ME
04030-5114
US

IV. Provider business mailing address

300 OLD ALFRED RD
EAST WATERBORO ME
04030-5114
US

V. Phone/Fax

Practice location:
  • Phone: 207-247-5682
  • Fax: 207-247-5682
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberALLS3315
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: