Healthcare Provider Details

I. General information

NPI: 1467689786
Provider Name (Legal Business Name): PEDS CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2009
Last Update Date: 06/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 WEBHANNET PL SUITE 2
KENNEBUNK ME
04043-7273
US

IV. Provider business mailing address

3 WEBHANNET PL SUITE 2
KENNEBUNK ME
04043-7273
US

V. Phone/Fax

Practice location:
  • Phone: 207-467-8215
  • Fax:
Mailing address:
  • Phone: 207-467-8215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number572387
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number572387
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number572387
License Number StateME
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number572387
License Number StateME
# 5
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number572387
License Number StateME
# 6
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number572387
License Number StateME
# 7
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number572387
License Number StateME
# 8
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number572387
License Number StateME
# 9
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number572387
License Number StateME
# 10
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number572387
License Number StateME
# 11
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL
# 12
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number572387
License Number StateME
# 13
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number572387
License Number StateME

VIII. Authorized Official

Name: MARI JO ALLEN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 207-467-8215