Basic Information
| Provider Information | |||||||||
| NPI: | 1689755530 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BROADLEAF BEHAVIORAL HEALTH PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 810 | ||||||||
| Address2: | |||||||||
| City: | WESTBROOK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040980810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005950033 | ||||||||
| FaxNumber: | 2078393190 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 OLD SAWMILL LN | ||||||||
| Address2: | |||||||||
| City: | ARUNDEL | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040468164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079858998 | ||||||||
| FaxNumber: | 2079851281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 04/13/2010 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE PROPRIETOR | ||||||||
| AuthorizedOfficialTelephone: | 2079858998 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084A0401X | ME1558 | ME | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 431879600 | 05 | ME | MEDICAID |