=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225497902
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREEDOM FIRST SUPPORT SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2016
-----------------------------------------------------
Last Update Date | 02/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 WARREN TER
-----------------------------------------------------
City | WINSLOW
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04901-7612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-649-1745
-----------------------------------------------------
Fax | 207-861-7037
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 WARREN TER
-----------------------------------------------------
City | WINSLOW
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04901-7612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-649-1745
-----------------------------------------------------
Fax | 207-861-7037
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MRS. TINA MARIE CHARTRAND
-----------------------------------------------------
Credential | L.S.W.
-----------------------------------------------------
Telephone | 207-649-1745
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------