Provider Demographics
NPI:1962762690
Name:WILLETTE, BERNADETTE
Entity type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
Last Name:WILLETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1841 BANGOR RD
Mailing Address - Street 2:
Mailing Address - City:LINNEUS
Mailing Address - State:ME
Mailing Address - Zip Code:04730-4601
Mailing Address - Country:US
Mailing Address - Phone:207-532-7575
Mailing Address - Fax:
Practice Address - Street 1:1841 BANGOR RD
Practice Address - Street 2:
Practice Address - City:LINNEUS
Practice Address - State:ME
Practice Address - Zip Code:04730-4601
Practice Address - Country:US
Practice Address - Phone:207-532-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC1780101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional