Basic Information
| Provider Information | |||||||||
| NPI: | 1164743381 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAINE BEHAVIORAL HEALTHCARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | SPRING HARBOR COMMUNITY SERVICES | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 78 ATLANTIC PL | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041062316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078427701 | ||||||||
| FaxNumber: | 2078427773 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 UNION ST | ||||||||
| Address2: | |||||||||
| City: | ROCKLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 048412739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077014400 | ||||||||
| FaxNumber: | 2077014485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2010 | ||||||||
| LastUpdateDate: | 06/10/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOWERS | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EVP & COO | ||||||||
| AuthorizedOfficialTelephone: | 2072532629 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 680905 | ME | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 435793100 | 05 | ME | MEDICAID | 435793101 | 05 | ME | MEDICAID |