Provider Demographics
NPI:1003180944
Name:SLAVEN-LAMOTHE, MICA T (LCSW, MHRT-CSP)
Entity Type:Individual
Prefix:
First Name:MICA
Middle Name:T
Last Name:SLAVEN-LAMOTHE
Suffix:
Gender:F
Credentials:LCSW, MHRT-CSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 BUCKSPORT RD
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605-2722
Mailing Address - Country:US
Mailing Address - Phone:207-667-6890
Mailing Address - Fax:207-687-6457
Practice Address - Street 1:710 BUCKSPORT RD
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-2722
Practice Address - Country:US
Practice Address - Phone:207-667-6890
Practice Address - Fax:207-687-6457
Is Sole Proprietor?:No
Enumeration Date:2012-02-23
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MELC147221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME103850000Medicaid