Provider Demographics
NPI:1497495675
Name:ROMAN, SUSAN LEE (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LEE
Last Name:ROMAN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 215
Mailing Address - Street 2:
Mailing Address - City:SOUTH GARDINER
Mailing Address - State:ME
Mailing Address - Zip Code:04359-0215
Mailing Address - Country:US
Mailing Address - Phone:207-837-1943
Mailing Address - Fax:
Practice Address - Street 1:22 FARWELL ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ME
Practice Address - Zip Code:04250-6824
Practice Address - Country:US
Practice Address - Phone:207-353-8118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL6489101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional