Healthcare Provider Details

I. General information

NPI: 1477579449
Provider Name (Legal Business Name): WARREN HOULETTE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 HIGH ST
FORT FAIRFIELD ME
04742-1021
US

IV. Provider business mailing address

23 HIGH ST
FORT FAIRFIELD ME
04742-1021
US

V. Phone/Fax

Practice location:
  • Phone: 207-768-4805
  • Fax: 207-768-4803
Mailing address:
  • Phone: 207-768-4805
  • Fax: 207-768-4803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC3379
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: