Provider Demographics
NPI:1649436908
Name:JEAN-LOUIS, POLO (LCSW)
Entity type:Individual
Prefix:MR
First Name:POLO
Middle Name:
Last Name:JEAN-LOUIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:POLOBERG
Other - Middle Name:
Other - Last Name:JEAN-LOUIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:612 GRAY RD
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-5808
Mailing Address - Country:US
Mailing Address - Phone:207-200-7050
Mailing Address - Fax:207-893-1865
Practice Address - Street 1:612 GRAY RD
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:ME
Practice Address - Zip Code:04038-5808
Practice Address - Country:US
Practice Address - Phone:207-200-7050
Practice Address - Fax:207-893-1865
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-05
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC134591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical