Provider Demographics
NPI:1043834153
Name:POULIN, TIA MARIE (LADC, CCS)
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:MARIE
Last Name:POULIN
Suffix:
Gender:F
Credentials:LADC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 NEW COUNTY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04841-5320
Mailing Address - Country:US
Mailing Address - Phone:207-596-0312
Mailing Address - Fax:207-596-0319
Practice Address - Street 1:166 NEW COUNTY RD
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841-5320
Practice Address - Country:US
Practice Address - Phone:207-596-0312
Practice Address - Fax:207-596-0319
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC4776101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)