Healthcare Provider Details

I. General information

NPI: 1982949699
Provider Name (Legal Business Name): PROVIDENCE SERVICE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

469 MAIN ST
SPRINGVALE ME
04083-1870
US

IV. Provider business mailing address

PO BOX 758866
BALTIMORE MD
21275-8866
US

V. Phone/Fax

Practice location:
  • Phone: 207-490-6600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number392123
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier19170000
Identifier TypeMEDICAID
Identifier StateME
Identifier Issuer

VIII. Authorized Official

Name: NICOLE ZENGA
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 207-373-0620