Provider Demographics
NPI:1982750774
Name:LEASURE, TERI (LCSW)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:
Last Name:LEASURE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 BARIBEAU DR
Mailing Address - Street 2:SUITE 8
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-3230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:66 BARIBEAU DR
Practice Address - Street 2:SUITE 8
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-3230
Practice Address - Country:US
Practice Address - Phone:207-373-6971
Practice Address - Fax:207-373-6959
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC57201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME102140100Medicaid