Provider Demographics
NPI:1255410643
Name:LELLO, MARY (MAC, LAC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LELLO
Suffix:
Gender:F
Credentials:MAC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-4973
Mailing Address - Country:US
Mailing Address - Phone:207-761-7228
Mailing Address - Fax:
Practice Address - Street 1:535 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-4973
Practice Address - Country:US
Practice Address - Phone:207-761-7228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAC 166174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist