Provider Demographics
NPI:1194200519
Name:ST LOUIS, KATRINA
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:ST LOUIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 LARKIN ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21 MAIN ST STE 301
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6359
Practice Address - Country:US
Practice Address - Phone:207-631-2201
Practice Address - Fax:207-631-2203
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC6584101YA0400X
MEMC180901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)