Provider Demographics
NPI:1457740706
Name:GENDREAU, LAWRENCE CHARLES (LADC)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:CHARLES
Last Name:GENDREAU
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 ESSEX ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4001
Mailing Address - Country:US
Mailing Address - Phone:207-478-2414
Mailing Address - Fax:
Practice Address - Street 1:98 CUMBERLAND ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5234
Practice Address - Country:US
Practice Address - Phone:207-941-1600
Practice Address - Fax:207-941-1608
Is Sole Proprietor?:No
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC5334101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)