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100 Brickhill Ave Ste 304 South Portland ME 04106-1999 | |
| (443) 359-1706 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 100 Brickhill Ave Ste 304, South Portland, Maine |
| Authorized Official Name and Position | Krystle Nicole Ladd (OWNER) |
| Authorized Official Contact | 4433591706 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
119 Quail Trl Buxton ME 04093-3219 Ph: (443) 359-1706 | 100 Brickhill Ave Ste 304 South Portland ME 04106-1999 Ph: (443) 359-1706 |
| NPI Number | 1215682455 |
|---|---|
| Provider Enumeration Date | 02/16/2022 |
| Last Update Date | 01/23/2025 |
| Certification Date | 01/23/2025 |
| Medicare PECOS PAC ID | 4183006935 |
|---|---|
| Medicare Enrollment ID | O20220727000496 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1215682455 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
| Provider Name | Krystle Nicole Ladd |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1700383742 PECOS PAC ID: 3779848361 Enrollment ID: I20181211002360 |
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