Provider Demographics
NPI:1174674279
Name:BIRNBERG, JONATHAN DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DAVID
Last Name:BIRNBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 POOL ST
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-9713
Mailing Address - Country:US
Mailing Address - Phone:207-775-2220
Mailing Address - Fax:207-775-2226
Practice Address - Street 1:609 MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-5453
Practice Address - Country:US
Practice Address - Phone:207-775-2220
Practice Address - Fax:207-775-2226
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1192103T00000X
MA8077103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW06273OtherBCBS OF MASS.
ME0005266OtherMEDICARE PTAN
MA808393000OtherMAGELLAN
MABI W51216Medicare ID - Type Unspecified