Provider Demographics
NPI:1073847299
Name:WEATHERBEE, NICOLA J (LADC)
Entity Type:Individual
Prefix:
First Name:NICOLA
Middle Name:J
Last Name:WEATHERBEE
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:NICOLA
Other - Middle Name:J
Other - Last Name:CANNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:RUMFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04276-2092
Mailing Address - Country:US
Mailing Address - Phone:207-364-1610
Mailing Address - Fax:207-364-1611
Practice Address - Street 1:28 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:RUMFORD
Practice Address - State:ME
Practice Address - Zip Code:04276-2092
Practice Address - Country:US
Practice Address - Phone:207-364-1610
Practice Address - Fax:207-364-1611
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC4564101YA0400X
MEXL4368101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME433007599OtherMAINECARE