Provider Demographics
NPI:1447727466
Name:EAST COAST WELLNESS LLC
Entity type:Organization
Organization Name:EAST COAST WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:207-400-5092
Mailing Address - Street 1:553 SHORE RD STE 2
Mailing Address - Street 2:
Mailing Address - City:CAPE ELIZABETH
Mailing Address - State:ME
Mailing Address - Zip Code:04107-1010
Mailing Address - Country:US
Mailing Address - Phone:207-400-5876
Mailing Address - Fax:
Practice Address - Street 1:553 SHORE RD STE 2
Practice Address - Street 2:
Practice Address - City:CAPE ELIZABETH
Practice Address - State:ME
Practice Address - Zip Code:04107-1010
Practice Address - Country:US
Practice Address - Phone:207-400-5876
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-29
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE300280666Medicaid
MEE300279945Medicaid