Healthcare Provider Details

I. General information

NPI: 1316166580
Provider Name (Legal Business Name): OLD TOWN SCHOOL DEPT.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 08/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 JEFFERSON ST
OLD TOWN ME
04468-2106
US

IV. Provider business mailing address

P.O. BOX 543 21 JEFFERSON STREET
OLD TOWN ME
04468-0543
US

V. Phone/Fax

Practice location:
  • Phone: 207-827-4441
  • Fax: 207-827-4449
Mailing address:
  • Phone: 207-827-4441
  • Fax: 207-827-4449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. ANNE MARIE BOUCHER
Title or Position: INTERIM DIRECTOR
Credential:
Phone: 207-827-4441