Provider Demographics
NPI:1801501119
Name:BOULOS PSYCHOLOGICAL SERVICES LLC
Entity type:Organization
Organization Name:BOULOS PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:207-671-7361
Mailing Address - Street 1:60 EDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CAPE ELIZABETH
Mailing Address - State:ME
Mailing Address - Zip Code:04107-1277
Mailing Address - Country:US
Mailing Address - Phone:207-671-7361
Mailing Address - Fax:
Practice Address - Street 1:60 EDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:CAPE ELIZABETH
Practice Address - State:ME
Practice Address - Zip Code:04107-1277
Practice Address - Country:US
Practice Address - Phone:207-671-7361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health