Provider Demographics
NPI:1093329294
Name:WITHERBY, IAN R C (LCSW)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:R C
Last Name:WITHERBY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 UNION ST
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04841-2739
Mailing Address - Country:US
Mailing Address - Phone:207-352-0300
Mailing Address - Fax:
Practice Address - Street 1:12 UNION ST
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841-2739
Practice Address - Country:US
Practice Address - Phone:207-352-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-04
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1230461041C0700X
MEMC171181041C0700X
MELC194431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical