Provider Demographics
NPI:1770034415
Name:IRONWOOD MAINE
Entity type:Organization
Organization Name:IRONWOOD MAINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:THIBODEAU
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW-CC
Authorized Official - Phone:207-342-3655
Mailing Address - Street 1:67 CAPTAIN CUSHMAN RD
Mailing Address - Street 2:
Mailing Address - City:MORRILL
Mailing Address - State:ME
Mailing Address - Zip Code:04952-5035
Mailing Address - Country:US
Mailing Address - Phone:207-345-3655
Mailing Address - Fax:207-342-3791
Practice Address - Street 1:67 CAPTAIN CUSHMAN RD
Practice Address - Street 2:
Practice Address - City:MORRILL
Practice Address - State:ME
Practice Address - Zip Code:04952-5035
Practice Address - Country:US
Practice Address - Phone:207-345-3655
Practice Address - Fax:207-342-3791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC16161322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children