Provider Demographics
NPI:1861153413
Name:SPRAGUE, TIA LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:LYNN
Last Name:SPRAGUE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TIA
Other - Middle Name:LYNN
Other - Last Name:JESELSKIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8 ROAD LESS TRAVELED RD
Mailing Address - Street 2:
Mailing Address - City:BRYANT POND
Mailing Address - State:ME
Mailing Address - Zip Code:04219-6729
Mailing Address - Country:US
Mailing Address - Phone:207-330-5046
Mailing Address - Fax:
Practice Address - Street 1:8 ROAD LESS TRAVELED RD
Practice Address - Street 2:
Practice Address - City:BRYANT POND
Practice Address - State:ME
Practice Address - Zip Code:04219-6729
Practice Address - Country:US
Practice Address - Phone:207-330-5046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-05
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC239481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical