Basic Information
| Provider Information | |||||||||
| NPI: | 1891733309 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAINE BEHAVIORAL HEALTHCARE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COUNSELING SERVICES, INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 78 ATLANTIC PL | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041062316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078427701 | ||||||||
| FaxNumber: | 2078427773 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 SPRINGBROOK DR | ||||||||
| Address2: | |||||||||
| City: | BIDDEFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040059443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072821500 | ||||||||
| FaxNumber: | 2072822581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 06/10/2014 | ||||||||
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| AuthorizedOfficialLastName: | BOWERS | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EVP & COO | ||||||||
| AuthorizedOfficialTelephone: | 2072532629 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 680905 | ME | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 105330000 | 05 | ME | MEDICAID | 1058005 | 01 | ME | CIGNA BEHAVIORAL HEALTH | OTHER | 003086 | 01 | ME | ANTHEM BC/BS | OTHER |