Provider Demographics
NPI:1619136983
Name:PSYCHODIAGNOSTIC SERVICES OF SOUTHERN MAINE
Entity Type:Organization
Organization Name:PSYCHODIAGNOSTIC SERVICES OF SOUTHERN MAINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARBONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-828-4026
Mailing Address - Street 1:491 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2636
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:491 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2636
Practice Address - Country:US
Practice Address - Phone:207-828-4026
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty