Provider Demographics
NPI:1770844904
Name:MALBOEUF, MARIE LOUISE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:LOUISE
Last Name:MALBOEUF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:LOUISE
Other - Last Name:MALBOEUF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:40 MANSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2018
Mailing Address - Country:US
Mailing Address - Phone:860-450-7471
Mailing Address - Fax:
Practice Address - Street 1:202 POMFRET ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1833
Practice Address - Country:US
Practice Address - Phone:860-963-7917
Practice Address - Fax:860-963-0015
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0089931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004040564Medicaid