Provider Demographics
NPI:1184867590
Name:DAWN OUELLETTE
Entity Type:Organization
Organization Name:DAWN OUELLETTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HOME PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:M
Authorized Official - Last Name:OUELLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-444-4562
Mailing Address - Street 1:13 SOUTH BROOK LANE
Mailing Address - Street 2:
Mailing Address - City:EAGLE LAKE
Mailing Address - State:ME
Mailing Address - Zip Code:04739
Mailing Address - Country:US
Mailing Address - Phone:207-444-4562
Mailing Address - Fax:207-444-4069
Practice Address - Street 1:13 SOUTH BROOK LANE
Practice Address - Street 2:
Practice Address - City:EAGLE LAKE
Practice Address - State:ME
Practice Address - Zip Code:04739
Practice Address - Country:US
Practice Address - Phone:207-444-4562
Practice Address - Fax:207-444-4069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-15
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME202220000Medicaid