1669701066 NPI number — MAINE BEHAVIORAL HEALTHCARE

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 1669701066 NPI number — MAINE BEHAVIORAL HEALTHCARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAINE BEHAVIORAL HEALTHCARE
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:
COMMUNITY COUNSELING CENTER
Provider Other Organization Name Type Code:
4
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:
1669701066
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
78 ATLANTIC PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04106-2316
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-842-7701
Provider Business Mailing Address Fax Number:
207-842-7773

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
165 LANCASTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04101-2406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-874-1030
Provider Business Practice Location Address Fax Number:
207-874-1044
Provider Enumeration Date:
12/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BOWERS
Authorized Official First Name:
GREG
Authorized Official Middle Name:
Authorized Official Title or Position:
EVP & COO
Authorized Official Telephone Number:
207-253-2629

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  680905 , 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)

  • Identifier: 104760000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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