Healthcare Provider Details

I. General information

NPI: 1790067130
Provider Name (Legal Business Name): STACEY A LAGRANGE CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2011
Last Update Date: 09/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PINE ST
LEWISTON ME
04240-6309
US

IV. Provider business mailing address

301 E HEBRON RD
TURNER ME
04282-4514
US

V. Phone/Fax

Practice location:
  • Phone: 207-777-3399
  • Fax:
Mailing address:
  • Phone: 207-225-5069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAC5044
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: