Provider Demographics
NPI:1477254134
Name:LEMELIN, MARK ANTHONY (LCDP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:LEMELIN
Suffix:
Gender:M
Credentials:LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 ADA ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02909-4906
Mailing Address - Country:US
Mailing Address - Phone:508-280-3749
Mailing Address - Fax:
Practice Address - Street 1:55 HOPE ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2001
Practice Address - Country:US
Practice Address - Phone:401-331-1350
Practice Address - Fax:401-277-3385
Is Sole Proprietor?:No
Enumeration Date:2023-03-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICDP00936101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)