Healthcare Provider Details

I. General information

NPI: 1639365349
Provider Name (Legal Business Name): BROADREACH FAMILY AND COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 04/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 STEPHENSON LN
BELFAST ME
04915-7230
US

IV. Provider business mailing address

5 STEPHENSON LN
BELFAST ME
04915-7230
US

V. Phone/Fax

Practice location:
  • Phone: 207-338-2200
  • Fax: 207-338-1652
Mailing address:
  • Phone: 207-338-2200
  • Fax: 207-338-1652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateME
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateME
# 5
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number403530
License Number StateME

VIII. Authorized Official

Name: MR. CLAIR BRADSTREET
Title or Position: CFO
Credential:
Phone: 207-338-2200