Provider Demographics
NPI:1073751277
Name:INDEPENDENCE PROJECT LLC
Entity Type:Organization
Organization Name:INDEPENDENCE PROJECT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/MEMBER/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:PELKEY
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:207-945-9777
Mailing Address - Street 1:96 HARLOW ST
Mailing Address - Street 2:SUITE 340
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4925
Mailing Address - Country:US
Mailing Address - Phone:207-945-9777
Mailing Address - Fax:207-945-9777
Practice Address - Street 1:96 HARLOW ST
Practice Address - Street 2:SUITE 340
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4925
Practice Address - Country:US
Practice Address - Phone:207-945-9777
Practice Address - Fax:207-945-9777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-26
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME467117101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431482300Medicaid