Basic Information
Provider Information
NPI: 1033216106
EntityType: 2
ReplacementNPI:  
OrganizationName: INGRAHAM
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 1868
Address2:  
City: PORTLAND
State: ME
PostalCode: 041041868
CountryCode: US
TelephoneNumber: 2078741055
FaxNumber: 2077745901
Practice Location
Address1: 50 MONUMENT SQ
Address2:  
City: PORTLAND
State: ME
PostalCode: 041014039
CountryCode: US
TelephoneNumber: 2078741055
FaxNumber: 2077745901
Other Information
ProviderEnumerationDate: 09/20/2006
LastUpdateDate: 08/22/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: MORRISON
AuthorizedOfficialFirstName: JANE
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: EXECUTIVE DIRECTOR
AuthorizedOfficialTelephone: 2078741055
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MRS.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QM0850X  Y Ambulatory Health Care FacilitiesClinic/CenterAdult Mental Health

No ID Information.


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