Provider Demographics
NPI: | 1568875029 |
---|---|
Name: | DESROSIER, SARA LOUISE (LCSW, LADC) |
Entity Type: | Individual |
Prefix: | |
First Name: | SARA |
Middle Name: | LOUISE |
Last Name: | DESROSIER |
Suffix: | |
Gender: | F |
Credentials: | LCSW, LADC |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 309 SAINT THOMAS ST STE 213 |
Mailing Address - Street 2: | |
Mailing Address - City: | MADAWASKA |
Mailing Address - State: | ME |
Mailing Address - Zip Code: | 04756-1278 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 207-728-3971 |
Mailing Address - Fax: | 207-728-3970 |
Practice Address - Street 1: | 309 SAINT THOMAS ST STE 213 |
Practice Address - Street 2: | |
Practice Address - City: | MADAWASKA |
Practice Address - State: | ME |
Practice Address - Zip Code: | 04756-1278 |
Practice Address - Country: | US |
Practice Address - Phone: | 207-728-3971 |
Practice Address - Fax: | 207-728-3970 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2014-06-03 |
Last Update Date: | 2022-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
ME | LC17780 | 1041C0700X, 1041C0700X |
ME | MC16377 | 104100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 104100000X | Behavioral Health & Social Service Providers | Social Worker | |
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
ME | 1568875029 | Medicaid |