Basic Information
| Provider Information | |||||||||
| NPI: | 1215946710 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCNEILL | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | CNS | ||||||||
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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: | 474 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGVALE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040831409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073241500 | ||||||||
| FaxNumber: | 2074905263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 09/24/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0808X | CNS84088 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health | 163W00000X | RN27793 | ME | N | Nursing Service Providers | Registered Nurse | 101YA0400X | LC184 | ME | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 269560099 | 05 | ME | MEDICAID |