Provider Demographics
NPI:1679504864
Name:KENNEBEC VALLEY MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:KENNEBEC VALLEY MENTAL HEALTH CENTER
Other - Org Name:KENNEBEC BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MCADAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-873-2136
Mailing Address - Street 1:67 EUSTIS PKWY
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-5173
Mailing Address - Country:US
Mailing Address - Phone:207-873-2136
Mailing Address - Fax:207-872-4522
Practice Address - Street 1:67 EUSTIS PKWY
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-5173
Practice Address - Country:US
Practice Address - Phone:207-873-2136
Practice Address - Fax:207-872-4522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME222762261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM4194Medicare ID - Type UnspecifiedLCSW'S
MEMM3166Medicare ID - Type UnspecifiedPSYCHOLOGISTS
MEMM0102Medicare ID - Type UnspecifiedMEDICARE