Healthcare Provider Details

I. General information

NPI: 1659959484
Provider Name (Legal Business Name): MANIFEST MAINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2021
Last Update Date: 04/01/2021
Certification Date: 04/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 MAIN ST
WESTBROOK ME
04092-2872
US

IV. Provider business mailing address

20 INKHORN BROOK RD
WINDHAM ME
04062-4091
US

V. Phone/Fax

Practice location:
  • Phone: 207-480-3491
  • Fax: 207-352-5133
Mailing address:
  • Phone: 207-838-7839
  • Fax:

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: WHITNEY ADAMS
Title or Position: OWNER
Credential: LCSW, LADC, CCS
Phone: 207-838-7839