Basic Information
Provider Information | |||||||||
NPI: | 1518193812 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE OPPORTUNITY ALLIANCE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 50 LYDIA LN | ||||||||
Address2: |   | ||||||||
City: | SOUTH PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041062156 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078741175 | ||||||||
FaxNumber: | 2078741181 | ||||||||
Practice Location | |||||||||
Address1: | 50 LYDIA LN | ||||||||
Address2: |   | ||||||||
City: | SOUTH PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041062156 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078741175 | ||||||||
FaxNumber: | 2078741181 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2009 | ||||||||
LastUpdateDate: | 10/09/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAWLEY | ||||||||
AuthorizedOfficialFirstName: | LAUREN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | REVENUE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2075235018 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X |   |   | N |   | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |   | 320800000X |   |   | Y |   | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |   |
ID Information
ID | Type | State | Issuer | Description | 105460200 | 05 | ME |   | MEDICAID | 105460229 | 05 | ME |   | MEDICAID | 105460218 | 05 | ME |   | MEDICAID | 105460226 | 05 | ME |   | MEDICAID | 105460227 | 05 | ME |   | MEDICAID | 105460212 | 05 | ME |   | MEDICAID | 105460215 | 05 | ME |   | MEDICAID | 105460233 | 05 | ME |   | MEDICAID | 105460202 | 05 | ME |   | MEDICAID | 105460205 | 05 | ME |   | MEDICAID | 105460201 | 05 | ME |   | MEDICAID | 105460217 | 05 | ME |   | MEDICAID | 105460225 | 05 | ME |   | MEDICAID | 105460228 | 05 | ME |   | MEDICAID | 105460206 | 05 | ME |   | MEDICAID | 105460230 | 05 | ME |   | MEDICAID | 105460203 | 05 | ME |   | MEDICAID | 105460231 | 05 | ME |   | MEDICAID | 105460204 | 05 | ME |   | MEDICAID |