=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659959484
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANIFEST MAINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2021
-----------------------------------------------------
Last Update Date | 04/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 825 MAIN ST
-----------------------------------------------------
City | WESTBROOK
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04092-2872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-480-3491
-----------------------------------------------------
Fax | 207-352-5133
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 INKHORN BROOK RD
-----------------------------------------------------
City | WINDHAM
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04062-4091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-838-7839
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WHITNEY ADAMS
-----------------------------------------------------
Credential | LCSW, LADC, CCS
-----------------------------------------------------
Telephone | 207-838-7839
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------