Provider Demographics
NPI:1083928451
Name:WITHAM, CAROL JEAN (MHRT-C)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:JEAN
Last Name:WITHAM
Suffix:
Gender:F
Credentials:MHRT-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 HAMMOND ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4610
Mailing Address - Country:US
Mailing Address - Phone:207-217-6711
Mailing Address - Fax:207-217-6712
Practice Address - Street 1:273 HAMMOND ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4610
Practice Address - Country:US
Practice Address - Phone:207-217-6711
Practice Address - Fax:207-217-6712
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-28
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMHRT-C171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator