Provider Demographics
NPI:1184639528
Name:ENTWISTLE, JUDITH L (LCSW)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:L
Last Name:ENTWISTLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 SMITHWHEEL RD APT 5
Mailing Address - Street 2:
Mailing Address - City:OLD ORCHARD BEACH
Mailing Address - State:ME
Mailing Address - Zip Code:04064-1035
Mailing Address - Country:US
Mailing Address - Phone:207-934-0563
Mailing Address - Fax:
Practice Address - Street 1:15 HOLLY ST
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-8867
Practice Address - Country:US
Practice Address - Phone:207-396-5335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC62501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME251270099Medicaid
ME251270099Medicaid