Provider Demographics
NPI:1649238494
Name:POULIN, MARLEE CLARE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARLEE
Middle Name:CLARE
Last Name:POULIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 STATE ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-5614
Mailing Address - Country:US
Mailing Address - Phone:207-623-7197
Mailing Address - Fax:207-623-7197
Practice Address - Street 1:112 STATE ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5614
Practice Address - Country:US
Practice Address - Phone:207-623-7197
Practice Address - Fax:207-623-7197
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC7538101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME0967Medicare PIN