Provider Demographics
NPI: | 1467689786 |
---|---|
Name: | PEDS CLINIC, INC |
Entity Type: | Organization |
Organization Name: | PEDS CLINIC, INC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | EXECUTIVE DIRECTOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MARI JO |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | ALLEN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 207-467-8215 |
Mailing Address - Street 1: | 3 WEBHANNET PL |
Mailing Address - Street 2: | SUITE 2 |
Mailing Address - City: | KENNEBUNK |
Mailing Address - State: | ME |
Mailing Address - Zip Code: | 04043-7273 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 207-467-8215 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 3 WEBHANNET PL |
Practice Address - Street 2: | SUITE 2 |
Practice Address - City: | KENNEBUNK |
Practice Address - State: | ME |
Practice Address - Zip Code: | 04043-7273 |
Practice Address - Country: | US |
Practice Address - Phone: | 207-467-8215 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2009-06-12 |
Last Update Date: | 2009-06-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
ME | 572387 | 101Y00000X, 101YA0400X, 101YM0800X, 103G00000X, 103TA0700X, 103TB0200X, 103TC2200X, 1041C0700X, 106H00000X, 2080A0000X, 225X00000X, 363LP0200X |
174400000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 174400000X | Other Service Providers | Specialist | Group - Multi-Specialty | |
No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Multi-Specialty | |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
No | 103G00000X | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | Group - Multi-Specialty | |
No | 103TA0700X | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging | Group - Multi-Specialty |
No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | Group - Multi-Specialty |
No | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | Group - Multi-Specialty |
No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | Group - Multi-Specialty | |
No | 2080A0000X | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | Group - Multi-Specialty |
No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
No | 363LP0200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | Group - Multi-Specialty |