Basic Information
Provider Information | |||||||||
NPI: | 1699014241 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNITED CEREBRAL PALSY OF NORTHEASTERN MAINE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 700 MOUNT HOPE AVE | ||||||||
Address2: | SUITE 320 | ||||||||
City: | BANGOR | ||||||||
State: | ME | ||||||||
PostalCode: | 044015680 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2079412952 | ||||||||
FaxNumber: | 2079412955 | ||||||||
Practice Location | |||||||||
Address1: | 700 MOUNT HOPE AVE | ||||||||
Address2: | SUITE 320 | ||||||||
City: | BANGOR | ||||||||
State: | ME | ||||||||
PostalCode: | 044015680 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2079412952 | ||||||||
FaxNumber: | 2079412955 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/01/2013 | ||||||||
LastUpdateDate: | 09/30/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARTIN | ||||||||
AuthorizedOfficialFirstName: | RONDA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 2079920602 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | 1699014241 | 05 | ME |   | MEDICAID |