MEDICARE: MARTHA DIANE LARIVIERE M.A., LMFT-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	XM4738	ME

General Provider Information

NPI Number	:	1285174656
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTHA DIANE LARIVIERE M.A., LMFT-C

Provider Business Mailing Address
First Line	:	25 DEAN DR
Second Line	:
City	:	NORTH WATERBORO
State	:	ME
Zip	:	04061-4300
Country	:	US
Telephone Number	:	207-315-9939
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 DEAN DR
Second Line	:
City	:	NORTH WATERBORO
State	:	ME
Zip	:	04061-4300
Country	:	US
Telephone Number	:	207-315-9939
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2017
Last Update Date	:	03/03/2017

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