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General NPI Number Information
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NPI Number | 1508188517
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Entity Type | Individual
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Provider Name | MYLES PETER OUELLETTE LADC, CCS
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Gender | Male
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Dates
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Enumeration Date | 02/17/2010
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Last Update Date | 06/07/2023
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Provider Practice Location Address
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Address Line | 200 CHAMPLAIN ST
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City | VAN BUREN
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State | ME
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Zip | 04785-1396
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Country | US
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Telephone | 207-436-5195
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 415
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City | VAN BUREN
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State | ME
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Zip | 04785-0415
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Country | US
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Telephone | 207-436-5195
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | X#MT3349
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License Number State | ME
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CCS7269
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License Number State | ME
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