Healthcare Provider Details

I. General information

NPI: 1407589641
Provider Name (Legal Business Name): JESSICA LEE-ANNE CORRIVEAU CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 07/06/2022
Certification Date: 07/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 EAST AVE
LEWISTON ME
04240-5662
US

IV. Provider business mailing address

14 SPEAR ST
LISBON FALLS ME
04252-6142
US

V. Phone/Fax

Practice location:
  • Phone: 207-777-3399
  • Fax: 207-777-3391
Mailing address:
  • Phone: 207-333-9509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAC8031
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: