Provider Demographics
NPI:1790910735
Name:PROULX, NICHOLE (LMFT)
Entity Type:Individual
Prefix:MS
First Name:NICHOLE
Middle Name:
Last Name:PROULX
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:692 W OLD TOWN RD
Mailing Address - Street 2:
Mailing Address - City:OLD TOWN
Mailing Address - State:ME
Mailing Address - Zip Code:04468-5715
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 COLLEGE CIR
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-2929
Practice Address - Country:US
Practice Address - Phone:207-941-7990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-20
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXM2969106H00000X
MEMF3946106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist