Provider Demographics
NPI:1083158356
Name:MISSUD MARTIN, LAURIENNE (LADC)
Entity Type:Individual
Prefix:
First Name:LAURIENNE
Middle Name:
Last Name:MISSUD MARTIN
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 ELM ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BERWICK
Mailing Address - State:ME
Mailing Address - Zip Code:03906-7100
Mailing Address - Country:US
Mailing Address - Phone:207-651-7573
Mailing Address - Fax:
Practice Address - Street 1:155 ELM ST
Practice Address - Street 2:
Practice Address - City:NORTH BERWICK
Practice Address - State:ME
Practice Address - Zip Code:03906-7100
Practice Address - Country:US
Practice Address - Phone:207-651-7573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC4443101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)