Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YM0800X | Mental Health Counselor | ||
Y | 1041C0700X | Clinical Social Worker | LC14722 | ME |
NPI | 1003180944 |
---|---|
Provider Name | Mica T. Slaven-Lamothe |
First Address | Ellsworth, ME 04605-2722 |
Second Address | Ellsworth, ME 04605-2722 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/02/2012 |
Last Update Date | 20/08/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
103850000 | (05) | ME |