Provider Demographics
NPI:1740356997
Name:BANGOR PSYCHIATRIC ASSOCIATES, PA
Entity type:Organization
Organization Name:BANGOR PSYCHIATRIC ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HENNEBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:207-907-6311
Mailing Address - Street 1:444 STILLWATER AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3500
Mailing Address - Country:US
Mailing Address - Phone:207-907-4311
Mailing Address - Fax:207-907-4322
Practice Address - Street 1:444 STILLWATER AVE STE 210
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3500
Practice Address - Country:US
Practice Address - Phone:207-907-4311
Practice Address - Fax:207-907-4322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME105740000Medicaid
ME048918OtherANTHEM
ME105740000Medicaid