Basic Information
| Provider Information | |||||||||
| NPI: | 1194200519 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ST LOUIS | ||||||||
| FirstName: | KATRINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 116 LARKIN ST APT 1 | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044016216 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 21 MAIN ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044016359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076312201 | ||||||||
| FaxNumber: | 2076312203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2018 | ||||||||
| LastUpdateDate: | 05/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CAC6584 | ME | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | MC18090 | ME | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.