Provider Demographics
NPI:1659483097
Name:RISEMAN, MANDIE LASSELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:MANDIE
Middle Name:LASSELLE
Last Name:RISEMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MANDIE
Other - Middle Name:MARIE
Other - Last Name:LASSELLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:7 OAK HILL TERRACE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074
Mailing Address - Country:US
Mailing Address - Phone:207-756-5425
Mailing Address - Fax:207-874-1044
Practice Address - Street 1:7 OAK HILL TERRACE
Practice Address - Street 2:SUITE 10
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074
Practice Address - Country:US
Practice Address - Phone:207-756-5425
Practice Address - Fax:207-874-1044
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC9956101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME267720099Medicaid
MEME1411Medicare ID - Type Unspecified