Provider Demographics
NPI:1760744601
Name:MAINE CHILD PSYCHOLOGY
Entity Type:Organization
Organization Name:MAINE CHILD PSYCHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:207-221-2631
Mailing Address - Street 1:14 STONEWALL WAY
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105-2491
Mailing Address - Country:US
Mailing Address - Phone:207-221-2631
Mailing Address - Fax:866-611-6717
Practice Address - Street 1:14 STONEWALL WAY
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04105-2491
Practice Address - Country:US
Practice Address - Phone:207-221-2631
Practice Address - Fax:866-611-6717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-15
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS593103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty