Healthcare Provider Details

I. General information

NPI: 1891409025
Provider Name (Legal Business Name): PSYCHMAINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2023
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 FOREST AVE STE 103
PORTLAND ME
04101-1505
US

IV. Provider business mailing address

550 FOREST AVE STE 103
PORTLAND ME
04101-1505
US

V. Phone/Fax

Practice location:
  • Phone: 207-221-0635
  • Fax: 207-221-0634
Mailing address:
  • Phone: 207-221-0635
  • Fax: 207-221-0634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN C FELLERS
Title or Position: PSYCHIATRIST
Credential: MD
Phone: 207-221-0635