Healthcare Provider Details

I. General information

NPI: 1598012304
Provider Name (Legal Business Name): STEPHANIE SUZANNE POULIN LMSW-CC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2012
Last Update Date: 08/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 EAST AVE
LEWISTON ME
04240-4776
US

IV. Provider business mailing address

899 RIVERSIDE ST
PORTLAND ME
04103-1070
US

V. Phone/Fax

Practice location:
  • Phone: 207-615-5926
  • Fax:
Mailing address:
  • Phone: 207-871-1211
  • Fax: 207-871-1232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberMC13650
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: