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General NPI Number Information
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NPI Number | 1598529125
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Entity Type | Organization
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Legal Business Name | BOREALIS MENTAL HEALTH SERVICES LLC
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Dates
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Enumeration Date | 02/13/2024
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Last Update Date | 02/13/2024
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Provider Practice Location Address
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Address Line | 61 MAIN ST STE 60
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City | BANGOR
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State | ME
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Zip | 04401-6469
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Country | US
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Telephone | 207-922-2158
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Fax |
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Provider Business Mailing Address
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Address Line | 61 MAIN ST STE 60
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City | BANGOR
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State | ME
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Zip | 04401-6469
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Country | US
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Telephone | 207-922-2158
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Fax |
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Authorized Official
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Title or Position | OWNER AND THERAPIST
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Name | TRISTAN GREENLAW
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Credential | MED. LCPC
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Telephone | 207-922-7572
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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