Provider Demographics
NPI:1093875437
Name:POULIN, DEBRA A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:A
Last Name:POULIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:A
Other - Last Name:KONIECZKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:31 COTTAGE WOOD RD.
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04222
Mailing Address - Country:US
Mailing Address - Phone:207-838-1247
Mailing Address - Fax:
Practice Address - Street 1:836 MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-2861
Practice Address - Country:US
Practice Address - Phone:207-854-0907
Practice Address - Fax:207-854-2597
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC100161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical