Provider Demographics
NPI:1811480452
Name:STONYBROOK MENTAL HEALTH
Entity type:Organization
Organization Name:STONYBROOK MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:COREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-664-8529
Mailing Address - Street 1:PO BOX 72
Mailing Address - Street 2:
Mailing Address - City:HOLDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04429-0072
Mailing Address - Country:US
Mailing Address - Phone:207-664-8529
Mailing Address - Fax:
Practice Address - Street 1:875 HAMMOND ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4303
Practice Address - Country:US
Practice Address - Phone:207-664-8529
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No251B00000XAgenciesCase Management
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities