Healthcare Provider Details

I. General information

NPI: 1447709431
Provider Name (Legal Business Name): MIDLANDS NEUROBEHAVIORAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2016
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 HAMMOND ST STE 4
BANGOR ME
04401-4586
US

IV. Provider business mailing address

621 HAMMOND ST STE 4
BANGOR ME
04401-4586
US

V. Phone/Fax

Practice location:
  • Phone: 207-307-7860
  • Fax: 888-352-7678
Mailing address:
  • Phone: 207-307-7860
  • Fax: 888-352-7678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1251
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1251
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. SHAWNA BLAKE KIRBY
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PHD
Phone: 207-307-7860