Basic Information
| Provider Information | |||||||||
| NPI: | 1215102850 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORNERSTONE BEHAVIORAL HEALTHCARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 157 PARK STREET | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044015000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079920410 | ||||||||
| FaxNumber: | 2079920414 | ||||||||
| Practice Location | |||||||||
| Address1: | 157 PARK STREET | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044015000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079920410 | ||||||||
| FaxNumber: | 2079920414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2008 | ||||||||
| LastUpdateDate: | 12/14/2010 | ||||||||
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| AuthorizedOfficialLastName: | WILLARD | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER, CEO | ||||||||
| AuthorizedOfficialTelephone: | 2079920410 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | IV | ||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 569364 | ME | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 432911500 | 05 | ME | MEDICAID |