Provider Demographics
NPI:1427602655
Name:MAINE MATERNAL LLC
Entity type:Organization
Organization Name:MAINE MATERNAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MALLORY
Authorized Official - Middle Name:
Authorized Official - Last Name:ZWERDLING
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:207-479-7841
Mailing Address - Street 1:52 BOLTON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2502
Mailing Address - Country:US
Mailing Address - Phone:207-479-7841
Mailing Address - Fax:
Practice Address - Street 1:52 BOLTON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2502
Practice Address - Country:US
Practice Address - Phone:207-479-7841
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-25
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health