Provider Demographics
NPI:1912017773
Name:POULIN, THERESA ROLANDE (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:ROLANDE
Last Name:POULIN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 80095
Mailing Address - Street 2:
Mailing Address - City:SOUTH DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02748-0095
Mailing Address - Country:US
Mailing Address - Phone:508-990-2077
Mailing Address - Fax:508-990-7808
Practice Address - Street 1:50 NORTH SECOND STREET
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740
Practice Address - Country:US
Practice Address - Phone:508-990-2077
Practice Address - Fax:508-990-7808
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10311291041C0700X
RIISWO13721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA26929600OtherHMO BLUE NEW ENGLAND
MA1857983Medicaid
MAP07727OtherBLUE CROSS BLUE SHIELD
MAP21173Medicare UPIN