Provider Demographics
NPI:1376045708
Name:DULAC, SARA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:DULAC
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 1:525 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5462
Mailing Address - Country:US
Mailing Address - Phone:207-767-0991
Mailing Address - Fax:
Practice Address - Street 1:525 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-5462
Practice Address - Country:US
Practice Address - Phone:207-767-0991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL5001101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1164484093Medicaid