Healthcare Provider Details

I. General information

NPI: 1033216106
Provider Name (Legal Business Name): INGRAHAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 MONUMENT SQ
PORTLAND ME
04101-4039
US

IV. Provider business mailing address

PO BOX 1868
PORTLAND ME
04104-1868
US

V. Phone/Fax

Practice location:
  • Phone: 207-874-1055
  • Fax: 207-774-5901
Mailing address:
  • Phone: 207-874-1055
  • Fax: 207-774-5901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. JANE MORRISON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 207-874-1055