Provider Demographics
NPI:1639216716
Name:PIERCE, PHILLIP JR
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:
Last Name:PIERCE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 DEER HILL LN
Mailing Address - Street 2:
Mailing Address - City:HAMPDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04444-3400
Mailing Address - Country:US
Mailing Address - Phone:207-862-0026
Mailing Address - Fax:
Practice Address - Street 1:46 DEER HILL LN
Practice Address - Street 2:
Practice Address - City:HAMPDEN
Practice Address - State:ME
Practice Address - Zip Code:04444-3400
Practice Address - Country:US
Practice Address - Phone:207-862-0026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEALLS 3008320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME208240000Medicaid