Provider Demographics
NPI:1003396037
Name:OUELLETTE, BRANDON L (LCPC-C)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:L
Last Name:OUELLETTE
Suffix:
Gender:M
Credentials:LCPC-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CARRIER WOOD RD APT 70
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7190
Mailing Address - Country:US
Mailing Address - Phone:207-551-7715
Mailing Address - Fax:
Practice Address - Street 1:71 US ROUTE 1 STE G
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7174
Practice Address - Country:US
Practice Address - Phone:207-774-3570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL5091101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor