Healthcare Provider Details

I. General information

NPI: 1831200575
Provider Name (Legal Business Name): PHOENIX MENTAL HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 STILLWATER AVE SUITE 202
BANGOR ME
04401-3500
US

IV. Provider business mailing address

444 STILLWATER AVE SUITE 202
BANGOR ME
04401-3500
US

V. Phone/Fax

Practice location:
  • Phone: 207-941-1113
  • Fax: 207-941-1134
Mailing address:
  • Phone: 207-941-1113
  • Fax: 207-941-1134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number492121
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number468197
License Number StateME

VIII. Authorized Official

Name: MS. BARBARA KERRIGAN
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW
Phone: 207-941-1113