Basic Information
| Provider Information | |||||||||
| NPI: | 1649909797 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THRIVEWORKS TELEPSYCHIATRY - MAINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 JEFFERSON ST STE 2C | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245041724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402176461 | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 FOREST AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041011505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552847483 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2022 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | NATHAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 5402176461 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.