Provider Demographics
NPI:1346330487
Name:EDITH, BARRY L (LCSW)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:L
Last Name:EDITH
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:PO BOX 2342
Mailing Address - Street 2:2201A&2201B
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-2342
Mailing Address - Country:US
Mailing Address - Phone:207-299-4947
Mailing Address - Fax:
Practice Address - Street 1:189 EXCHANGE ST
Practice Address - Street 2:2201A &2201B
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6507
Practice Address - Country:US
Practice Address - Phone:207-299-4947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC122641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME319070099Medicaid