Provider Demographics
NPI:1205210127
Name:MCELLIGOTT, JAMES (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:MCELLIGOTT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 BAXTER BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-1827
Mailing Address - Country:US
Mailing Address - Phone:207-774-8700
Mailing Address - Fax:
Practice Address - Street 1:53 BAXTER BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-1827
Practice Address - Country:US
Practice Address - Phone:207-774-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1573103TC0700X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1205210127Medicaid