Provider Demographics
NPI:1518201250
Name:UNIVERSITY OF SOUTHERN MAINE
Entity Type:Organization
Organization Name:UNIVERSITY OF SOUTHERN MAINE
Other - Org Name:HEALTH & COUNSELING SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, HEALTH SERVICES
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:GARNER
Authorized Official - Last Name:BELANGER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:207-780-5160
Mailing Address - Street 1:37 COLLEGE AVE
Mailing Address - Street 2:125 UPTON HALL
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-1032
Mailing Address - Country:US
Mailing Address - Phone:207-780-5411
Mailing Address - Fax:207-780-4911
Practice Address - Street 1:37 COLLEGE AVE
Practice Address - Street 2:125 UPTON HALL
Practice Address - City:GORHAM
Practice Address - State:ME
Practice Address - Zip Code:04038-1032
Practice Address - Country:US
Practice Address - Phone:207-780-5411
Practice Address - Fax:207-780-4911
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF MAINE SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME21136363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty