Provider Demographics
NPI:1508377193
Name:FEAR, LAURIE MATSON (LADC)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:MATSON
Last Name:FEAR
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 RIDGELAND AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-4130
Mailing Address - Country:US
Mailing Address - Phone:434-960-7769
Mailing Address - Fax:
Practice Address - Street 1:918 BROADWAY
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-4329
Practice Address - Country:US
Practice Address - Phone:434-960-7769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-23
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC6757101YA0400X
MECAC6240101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty