Healthcare Provider Details

I. General information

NPI: 1992096515
Provider Name (Legal Business Name): MAINE BEHAVIORAL HEALTH ORGANIZATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2011
Last Update Date: 04/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 NORTH RD
ATHENS ME
04912-4004
US

IV. Provider business mailing address

49 OAK ST
AUGUSTA ME
04330-5118
US

V. Phone/Fax

Practice location:
  • Phone: 207-654-2429
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number623004
License Number StateME

VIII. Authorized Official

Name: HILLARY KIMBALL-WHITE
Title or Position: CEO
Credential:
Phone: 207-399-5589