Provider Demographics
NPI:1508188517
Name:OUELLETTE, MYLES PETER (LADC, CCS)
Entity Type:Individual
Prefix:
First Name:MYLES
Middle Name:PETER
Last Name:OUELLETTE
Suffix:
Gender:M
Credentials:LADC, CCS
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 415
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:ME
Mailing Address - Zip Code:04785-0415
Mailing Address - Country:US
Mailing Address - Phone:207-436-5195
Mailing Address - Fax:
Practice Address - Street 1:200 CHAMPLAIN ST
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:ME
Practice Address - Zip Code:04785-1396
Practice Address - Country:US
Practice Address - Phone:207-436-5195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-17
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEX#MT3349225700000X
MECCS7269101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist