Basic Information
| Provider Information | |||||||||
| NPI: | 1740513282 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENNEBEC VALLEY MENTAL HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KENNEBEC BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 67 EUSTIS PKWY | ||||||||
| Address2: | |||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049015173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078732136 | ||||||||
| FaxNumber: | 2078724522 | ||||||||
| Practice Location | |||||||||
| Address1: | 67 EUSTIS PKWY | ||||||||
| Address2: | |||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049015173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078732136 | ||||||||
| FaxNumber: | 2078724522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2009 | ||||||||
| LastUpdateDate: | 09/16/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCADAM | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2078732136 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KENNEBEC MENTAL HEALTH ASSOCIATES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | 222762 | ME | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 102980002 | 05 | ME | MEDICAID |