Provider Demographics
NPI:1942595343
Name:AMICUS
Entity type:Organization
Organization Name:AMICUS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:R
Authorized Official - Last Name:GODSOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-941-2892
Mailing Address - Street 1:96 13TH ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4538
Mailing Address - Country:US
Mailing Address - Phone:207-941-2892
Mailing Address - Fax:207-941-2888
Practice Address - Street 1:96 13TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4538
Practice Address - Country:US
Practice Address - Phone:207-941-2892
Practice Address - Fax:207-941-2888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431573400Medicaid