Healthcare Provider Details

I. General information

NPI: 1982076485
Provider Name (Legal Business Name): FORESIDE BEHAVIOR ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 11/23/2022
Certification Date: 11/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 WASHINGTON AVE STE 302
PORTLAND ME
04103-3675
US

IV. Provider business mailing address

1321 WASHINGTON AVE STE 302
PORTLAND ME
04103-3675
US

V. Phone/Fax

Practice location:
  • Phone: 207-613-7324
  • Fax: 207-613-7333
Mailing address:
  • Phone: 207-613-7324
  • Fax: 207-613-7333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. SUSAN JARMUZ-SMITH
Title or Position: CLINICAL DIRECTOR
Credential: PSYD, BCBA-D
Phone: 207-613-7324