Provider Demographics
NPI:1144692880
Name:MAINE GEROPSYCHOLOGY, LLC
Entity type:Organization
Organization Name:MAINE GEROPSYCHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORTHLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:207-721-8143
Mailing Address - Street 1:14 MAINE ST
Mailing Address - Street 2:SUITE 111-C
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2049
Mailing Address - Country:US
Mailing Address - Phone:207-721-8143
Mailing Address - Fax:207-721-8143
Practice Address - Street 1:14 MAINE ST
Practice Address - Street 2:SUITE 111-C
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2049
Practice Address - Country:US
Practice Address - Phone:207-721-8143
Practice Address - Fax:207-721-8143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-21
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1413261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health