Provider Demographics
NPI:1689755530
Name:BROADLEAF BEHAVIORAL HEALTH PC
Entity Type:Organization
Organization Name:BROADLEAF BEHAVIORAL HEALTH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:207-985-8998
Mailing Address - Street 1:PO BOX 810
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04098-0810
Mailing Address - Country:US
Mailing Address - Phone:800-595-0033
Mailing Address - Fax:207-839-3190
Practice Address - Street 1:9 OLD SAWMILL LN
Practice Address - Street 2:
Practice Address - City:ARUNDEL
Practice Address - State:ME
Practice Address - Zip Code:04046-8164
Practice Address - Country:US
Practice Address - Phone:207-985-8998
Practice Address - Fax:207-985-1281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEME15582084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431879600Medicaid
MEME2380Medicare PIN