Provider Demographics
NPI:1063503522
Name:AVERILL, MARJORIE ELAINE (MSW LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARJORIE
Middle Name:ELAINE
Last Name:AVERILL
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:NOBLEBORO
Mailing Address - State:ME
Mailing Address - Zip Code:04555
Mailing Address - Country:US
Mailing Address - Phone:207-563-3022
Mailing Address - Fax:
Practice Address - Street 1:73 BISCAY ROAD
Practice Address - Street 2:
Practice Address - City:DAMARISCOTTA
Practice Address - State:ME
Practice Address - Zip Code:04542
Practice Address - Country:US
Practice Address - Phone:207-563-3022
Practice Address - Fax:207-563-3061
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC7078101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432269200Medicaid
ME204920100Medicaid
ME1700996063OtherNPI
ME432269200Medicaid