Provider Demographics
NPI:1972559045
Name:GOSSELIN, SUZANNE T (LCSW)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:T
Last Name:GOSSELIN
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 1:14 GOSLING ROAD
Mailing Address - Street 2:
Mailing Address - City:SHAPLEIGH
Mailing Address - State:ME
Mailing Address - Zip Code:04076
Mailing Address - Country:US
Mailing Address - Phone:207-793-3495
Mailing Address - Fax:
Practice Address - Street 1:137 S HIRAM RD
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:ME
Practice Address - Zip Code:04041-3636
Practice Address - Country:US
Practice Address - Phone:207-625-7134
Practice Address - Fax:207-625-7186
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC107421041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME207970199Medicaid