Healthcare Provider Details

I. General information

NPI: 1376830752
Provider Name (Legal Business Name): RENEE PERREAULT CADC, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 OCEAN AVE
PORTLAND ME
04103-4937
US

IV. Provider business mailing address

222 SAINT JOHN ST
PORTLAND ME
04102-3000
US

V. Phone/Fax

Practice location:
  • Phone: 207-518-6041
  • Fax:
Mailing address:
  • Phone: 72-560-3422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAC7394
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: