Healthcare Provider Details

I. General information

NPI: 1831311968
Provider Name (Legal Business Name): NORTHERN LIGHTHOUSE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 02/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MAIN ST
MARS HILL ME
04758
US

IV. Provider business mailing address

PO BOX 498
MARS HILL ME
04758-0498
US

V. Phone/Fax

Practice location:
  • Phone: 207-425-3880
  • Fax:
Mailing address:
  • Phone: 207-425-3880
  • Fax: 207-425-9048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number StateME

VIII. Authorized Official

Name: MR. SCOTT ALAN CRAY SR.
Title or Position: HUMAN RESOURCE ADMIN
Credential:
Phone: 207-554-5114