Provider Demographics
NPI:1598012304
Name:POULIN, STEPHANIE SUZANNE (LMSW-CC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:SUZANNE
Last Name:POULIN
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 1:899 RIVERSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1070
Mailing Address - Country:US
Mailing Address - Phone:207-871-1211
Mailing Address - Fax:207-871-1232
Practice Address - Street 1:407 EAST AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-4776
Practice Address - Country:US
Practice Address - Phone:207-615-5926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC136501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical