Healthcare Provider Details

I. General information

NPI: 1689335184
Provider Name (Legal Business Name): WABANAKI PUBLIC HEALTH AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2022
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 PARK ST
BANGOR ME
04401-5093
US

IV. Provider business mailing address

PO BOX 1356
BANGOR ME
04402-1356
US

V. Phone/Fax

Practice location:
  • Phone: 207-631-1536
  • Fax: 207-631-0524
Mailing address:
  • Phone: 207-992-0411
  • Fax: 207-631-0524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SHARON MAE JORDAN
Title or Position: DIRECTOR
Credential: LCSW
Phone: 207-992-0411