Healthcare Provider Details

I. General information

NPI: 1083917397
Provider Name (Legal Business Name): MICHAEL GRENIER LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2010
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 MAIN ST
NORWAY ME
04268-5943
US

IV. Provider business mailing address

235 MAIN ST
NORWAY ME
04268-5943
US

V. Phone/Fax

Practice location:
  • Phone: 207-739-2644
  • Fax: 207-739-2467
Mailing address:
  • Phone: 207-739-2644
  • Fax: 207-739-2467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLC5430
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: