Provider Demographics
NPI:1881627958
Name:FOOD ADDICTION CHEMICAL DEPENDENCY CONSULTANTS LLC
Entity type:Organization
Organization Name:FOOD ADDICTION CHEMICAL DEPENDENCY CONSULTANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DRUSILLA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:LADC CCS
Authorized Official - Phone:207-774-4564
Mailing Address - Street 1:650 MAIN ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SO PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-774-4564
Mailing Address - Fax:207-774-0006
Practice Address - Street 1:650 MAIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:SO PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106
Practice Address - Country:US
Practice Address - Phone:207-774-4564
Practice Address - Fax:207-774-0006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME454002101YM0800X
ME22146101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME126240100Medicaid