Basic Information
| Provider Information | |||||||||
| NPI: | 1306089917 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPURWINK SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 899 RIVERSIDE ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041031070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078711200 | ||||||||
| FaxNumber: | 2078711232 | ||||||||
| Practice Location | |||||||||
| Address1: | 587 OCEAN AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041032701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078711582 | ||||||||
| FaxNumber: | 2078719276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2009 | ||||||||
| LastUpdateDate: | 04/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | STILES | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2078711200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 252Y00000X | 502759 | ME | N | Agencies | Early Intervention Provider Agency | 251S00000X | 229881 | ME | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 105920000 | 05 | ME | MEDICAID |