Basic Information
| Provider Information | |||||||||
| NPI: | 1649503665 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SWEETSER | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 50 MOODY ST | ||||||||
| Address2: | |||||||||
| City: | SACO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040721536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004343000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 50 MOODY ST | ||||||||
| Address2: | |||||||||
| City: | SACO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040721536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004343000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2009 | ||||||||
| LastUpdateDate: | 10/20/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2072944651 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 102010102 | 05 | ME | MEDICAID |