Healthcare Provider Details

I. General information

NPI: 1881832640
Provider Name (Legal Business Name): BACK TO BASICS BEHAVIORAL HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2009
Last Update Date: 01/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 DEPOT RD
LEBANON ME
04027-3347
US

IV. Provider business mailing address

44 DEPOT RD
LEBANON ME
04027-3347
US

V. Phone/Fax

Practice location:
  • Phone: 207-651-4295
  • Fax: 207-457-6056
Mailing address:
  • Phone: 207-651-4295
  • Fax: 207-457-6056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License NumberCS1-11-963
License Number StateME

VIII. Authorized Official

Name: GARY PAUL GROVER
Title or Position: CEO
Credential:
Phone: 207-651-4295