Healthcare Provider Details

I. General information

NPI: 1811404098
Provider Name (Legal Business Name): RISE UP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2018
Last Update Date: 01/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 PARK ROW STE 103
BRUNSWICK ME
04011-2053
US

IV. Provider business mailing address

153 PARK ROW STE 103
BRUNSWICK ME
04011-2053
US

V. Phone/Fax

Practice location:
  • Phone: 207-504-3587
  • Fax:
Mailing address:
  • Phone: 207-504-3587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberCC4601
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberCC4601
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberCC4601
License Number StateME

VIII. Authorized Official

Name: JESSICA PACKARD
Title or Position: OWNER
Credential: LCPC
Phone: 207-504-3587