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General NPI Number Information
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NPI Number | 1821401076
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Entity Type | Organization
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Legal Business Name | CAMP KETCHA
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Dates
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Enumeration Date | 06/05/2014
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Last Update Date | 06/05/2014
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Provider Practice Location Address
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Address Line | 336 BLACK POINT RD
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City | SCARBOROUGH
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State | ME
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Zip | 04074-8676
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Country | US
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Telephone | 207-883-8977
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Fax | 207-885-0944
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Provider Business Mailing Address
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Address Line | 336 BLACK POINT RD
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City | SCARBOROUGH
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State | ME
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Zip | 04074-8676
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Country | US
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Telephone | 207-883-8977
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Fax | 207-885-0944
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. THOMAS DOHERTY
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Credential | MSW
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Telephone | 207-883-8977
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 681191
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License Number State | ME
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