1235840612 NPI number — ROOTS & RIPTIDES PSYCHOTHERAPY PLLC

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 1235840612 NPI number — ROOTS & RIPTIDES PSYCHOTHERAPY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROOTS & RIPTIDES PSYCHOTHERAPY PLLC
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:
1235840612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 182
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YORK HARBOR
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
03911-0182
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-248-1818
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 MARKET PLACE DR STE 201D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YORK
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
03909-1552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-994-9453
Provider Business Practice Location Address Fax Number:
207-221-1711
Provider Enumeration Date:
12/07/2022

Additional Information

Authorized Official

Authorized Official Last Name:
BOYLE
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
207-248-1818

Provider Taxonomy Codes

  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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