Provider Demographics
NPI:1821401076
Name:CAMP KETCHA
Entity Type:Organization
Organization Name:CAMP KETCHA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DOHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:207-883-8977
Mailing Address - Street 1:336 BLACK POINT RD
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-8676
Mailing Address - Country:US
Mailing Address - Phone:207-883-8977
Mailing Address - Fax:207-885-0944
Practice Address - Street 1:336 BLACK POINT RD
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-8676
Practice Address - Country:US
Practice Address - Phone:207-883-8977
Practice Address - Fax:207-885-0944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME681191251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health