Basic Information
| Provider Information | |||||||||
| NPI: | 1588989677 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YOUTH ALTERNATIVES INGRAHAM | ||||||||
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| 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: | 03/31/2010 | ||||||||
| LastUpdateDate: | 03/31/2010 | ||||||||
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| AuthorizedOfficialLastName: | HAWLEY | ||||||||
| AuthorizedOfficialFirstName: | LAUREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | FINANCIAL ANALYST | ||||||||
| AuthorizedOfficialTelephone: | 2078741175 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 230741 | ME | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 105460302 | 05 | ME | MEDICAID |