Provider Demographics
NPI:1053921437
Name:WAKEMAN, LAURA MALONE (LCSW-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MALONE
Last Name:WAKEMAN
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 MOOSENECK RD
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:ME
Mailing Address - Zip Code:04606-3543
Mailing Address - Country:US
Mailing Address - Phone:617-272-6658
Mailing Address - Fax:
Practice Address - Street 1:160 DUBLIN ST
Practice Address - Street 2:
Practice Address - City:MACHIAS
Practice Address - State:ME
Practice Address - Zip Code:04654-3409
Practice Address - Country:US
Practice Address - Phone:207-255-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-31
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD26104104100000X
MELC230791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker