Basic Information
| Provider Information | |||||||||
| NPI: | 1093933558 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNITED CEREBRAL PALSY OF NORTHEASTERN MAINE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | UCP OF MAINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 700 MOUNT HOPE AVE STE 320 | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044015680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079412952 | ||||||||
| FaxNumber: | 2079412955 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 MOUNT HOPE AVE STE 320 | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044015680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079412952 | ||||||||
| FaxNumber: | 2079412955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 10/03/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | YEAGER | ||||||||
| AuthorizedOfficialFirstName: | BOBBI-JO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2079412952 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251300000X | 4036849 | ME | Y | Agencies | Local Education Agency (LEA) |
ID Information
| ID | Type | State | Issuer | Description | 167950600 | 05 | ME | MEDICAID |