1144692880 NPI number — MAINE GEROPSYCHOLOGY, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144692880 NPI number — MAINE GEROPSYCHOLOGY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAINE GEROPSYCHOLOGY, LLC
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:
Provider Other Organization Name Type Code:
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:
1144692880
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14 MAINE ST
Provider Second Line Business Mailing Address:
SUITE 111-C
Provider Business Mailing Address City Name:
BRUNSWICK
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04011-2049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-721-8143
Provider Business Mailing Address Fax Number:
207-721-8143

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14 MAINE ST
Provider Second Line Business Practice Location Address:
SUITE 111-C
Provider Business Practice Location Address City Name:
BRUNSWICK
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04011-2049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-721-8143
Provider Business Practice Location Address Fax Number:
207-721-8143
Provider Enumeration Date:
10/21/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MORTHLAND
Authorized Official First Name:
MARTIN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
207-721-8143

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X , with the licence number:  PS1413 , 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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