Basic Information
Provider Information
NPI: 1104060045
EntityType: 2
ReplacementNPI:  
OrganizationName: ST . ANDRE'S HOME, INC.
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
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Mailing Information
Address1: 283 ELM ST
Address2:  
City: BIDDEFORD
State: ME
PostalCode: 040053027
CountryCode: US
TelephoneNumber: 2072823351
FaxNumber: 2072828733
Practice Location
Address1: 283 ELM ST
Address2:  
City: BIDDEFORD
State: ME
PostalCode: 040053027
CountryCode: US
TelephoneNumber: 2072823351
FaxNumber: 2072828733
Other Information
ProviderEnumerationDate: 04/22/2009
LastUpdateDate: 04/22/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: FITZPATRICK
AuthorizedOfficialFirstName: PETER
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: EXECUTIVE DIRECTOR
AuthorizedOfficialTelephone: 2072823351
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
251B00000X218677MEN AgenciesCase Management 
320800000X214603,429481,216796MEY Residential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness 

ID Information
IDTypeStateIssuerDescription
16823010001MEOUTREACH COMMUNITY SERVICESOTHER
1682300005ME MEDICAID


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