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General NPI Number Information
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NPI Number | 1881832640
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Entity Type | Organization
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Legal Business Name | BACK TO BASICS BEHAVIORAL HEALTH SERVICES, INC.
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Dates
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Enumeration Date | 01/31/2009
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Last Update Date | 01/31/2009
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Provider Practice Location Address
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Address Line | 44 DEPOT RD
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City | LEBANON
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State | ME
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Zip | 04027-3347
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Country | US
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Telephone | 207-651-4295
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Fax | 207-457-6056
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Provider Business Mailing Address
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Address Line | 44 DEPOT RD
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City | LEBANON
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State | ME
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Zip | 04027-3347
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Country | US
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Telephone | 207-651-4295
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Fax | 207-457-6056
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Authorized Official
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Title or Position | CEO
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Name | GARY PAUL GROVER
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Credential |
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Telephone | 207-651-4295
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number | CS1-11-963
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License Number State | ME
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