Healthcare Provider Details

I. General information

NPI: 1508936196
Provider Name (Legal Business Name): MENTAL HEALTH ASSOCIATES OF MAINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 10/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 WOODFORD ST
PORTLAND ME
04103-5617
US

IV. Provider business mailing address

251 WOODFORD ST
PORTLAND ME
04103-5617
US

V. Phone/Fax

Practice location:
  • Phone: 207-773-2828
  • Fax: 207-761-8150
Mailing address:
  • Phone: 207-773-2828
  • Fax: 207-761-8150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: CARLA KINGSTON
Title or Position: ADMINISTRATOR
Credential:
Phone: 207-773-2828