Provider Demographics
NPI:1518321181
Name:OUELLETTE, LISA MARIE (LMSW-CC)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:OUELLETTE
Suffix:
Gender:F
Credentials:LMSW-CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 SUMMER ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6467
Mailing Address - Country:US
Mailing Address - Phone:207-561-9533
Mailing Address - Fax:207-561-9538
Practice Address - Street 1:30 SUMMER ST
Practice Address - Street 2:SUITE 5
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6467
Practice Address - Country:US
Practice Address - Phone:207-561-9533
Practice Address - Fax:207-561-9538
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC159771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical