Basic Information
Provider Information | |||||||||
NPI: | 1568477297 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ACADIA HEALTHCARE, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P.O. BOX 442 | ||||||||
Address2: |   | ||||||||
City: | BANGOR | ||||||||
State: | ME | ||||||||
PostalCode: | 044020422 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2079736100 | ||||||||
FaxNumber: | 2079736109 | ||||||||
Practice Location | |||||||||
Address1: | 268 STILLWATER AVENUE | ||||||||
Address2: |   | ||||||||
City: | BANGOR | ||||||||
State: | ME | ||||||||
PostalCode: | 04401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2079736100 | ||||||||
FaxNumber: | 2079736109 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/30/2006 | ||||||||
LastUpdateDate: | 01/03/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SUITTER | ||||||||
AuthorizedOfficialFirstName: | MARIE | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | VP OF FINANCE AND OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 2079735110 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X |   | ME | N |   | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 324500000X | ARC 231302 | ME | N |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |   | 261QM0801X |   | ME | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 1568477297 | 05 | ME |   | MEDICAID |