Healthcare Provider Details

I. General information

NPI: 1821138017
Provider Name (Legal Business Name): NICHOLE LAVALLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1461 MOOSEHEAD TRL
JACKSON ME
04921
US

IV. Provider business mailing address

119 LOWER DETROIT RD
PLYMOUTH ME
04969-3213
US

V. Phone/Fax

Practice location:
  • Phone: 207-907-2631
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberALLS 2297
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: