Healthcare Provider Details

I. General information

NPI: 1134426323
Provider Name (Legal Business Name): THE AWARE CENTER FOR EARLY INTERVENTION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2011
Last Update Date: 02/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 MAIN ST SUITE 53
BANGOR ME
04401-6397
US

IV. Provider business mailing address

61 MAIN ST SUITE 53
BANGOR ME
04401-6397
US

V. Phone/Fax

Practice location:
  • Phone: 207-208-8301
  • Fax: 877-320-4344
Mailing address:
  • Phone: 207-208-8301
  • Fax: 877-320-4344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS1219
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC10927
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP081171
License Number StateME

VIII. Authorized Official

Name: DR. JESSICA POLLARD
Title or Position: DIRECTOR
Credential: PHD
Phone: 207-208-8301