Basic Information
| Provider Information | |||||||||
| NPI: | 1538122445 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SWEETSER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 MOODY STREET | ||||||||
| Address2: | |||||||||
| City: | SACO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004343000 | ||||||||
| FaxNumber: | 2072944649 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 MOODY STREET | ||||||||
| Address2: | |||||||||
| City: | SACO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004343000 | ||||||||
| FaxNumber: | 2072944649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 12/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 2072944651 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TP2701X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | 261QM0801X | 229941 | ME | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1538122445 | 05 | ME | MEDICAID |