1275645939 NPI number — TIDESIDE CLINICAL & PSYCHOLOGICAL SERVICES

Table of content: (NPI 1275645939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275645939 NPI number — TIDESIDE CLINICAL & PSYCHOLOGICAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIDESIDE CLINICAL & PSYCHOLOGICAL SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
TIDESIDE
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275645939
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
94 MILL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORONO
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04473-4040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-866-2636
Provider Business Mailing Address Fax Number:
207-669-6011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
64 CHURCH ST
Provider Second Line Business Practice Location Address:
TIDESIDE
Provider Business Practice Location Address City Name:
ELLSWORTH
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04605-1658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-669-6011
Provider Business Practice Location Address Fax Number:
207-669-6011
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BEATTIE
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
SOLE OWNER
Authorized Official Telephone Number:
207-669-6011

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PS1018 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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