Provider Demographics
NPI:1992702955
Name:SHALOM HOUSE, INC.
Entity type:Organization
Organization Name:SHALOM HOUSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYNES-RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-874-1080
Mailing Address - Street 1:106 GILMAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3034
Mailing Address - Country:US
Mailing Address - Phone:207-874-1080
Mailing Address - Fax:207-874-1077
Practice Address - Street 1:106 GILMAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3034
Practice Address - Country:US
Practice Address - Phone:207-874-1080
Practice Address - Fax:207-874-1077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-06
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME229743251B00000X, 320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME16780000Medicaid
ME167860101Medicaid
ME167860101Medicaid