Provider Demographics
NPI:1205014933
Name:POULIN, RICK E (LISAC)
Entity Type:Individual
Prefix:
First Name:RICK
Middle Name:E
Last Name:POULIN
Suffix:
Gender:M
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:483 W. SEED FARM RD.
Mailing Address - Street 2:NEW BEGINNINGS BUILDING
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85247-0038
Mailing Address - Country:US
Mailing Address - Phone:602-528-7164
Mailing Address - Fax:602-528-1374
Practice Address - Street 1:483 W. SEED FARM RD.
Practice Address - Street 2:NEW BEGINNINGS BUILDING
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85247-0038
Practice Address - Country:US
Practice Address - Phone:602-528-7164
Practice Address - Fax:602-528-1374
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10549101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ346214Medicaid