Provider Demographics
NPI:1356496483
Name:INGRAHAM
Entity Type:Organization
Organization Name:INGRAHAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-874-1055
Mailing Address - Street 1:50 MONUMENT SQ
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4039
Mailing Address - Country:US
Mailing Address - Phone:207-874-1055
Mailing Address - Fax:207-775-4034
Practice Address - Street 1:50 MONUMENT SQ
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4039
Practice Address - Country:US
Practice Address - Phone:207-874-1055
Practice Address - Fax:207-775-4034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC10806251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health