Provider Demographics
NPI:1417019274
Name:EDDY, MARINA D (LICSW)
Entity Type:Individual
Prefix:MS
First Name:MARINA
Middle Name:D
Last Name:EDDY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 BRIARWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2775
Mailing Address - Country:US
Mailing Address - Phone:207-233-5778
Mailing Address - Fax:
Practice Address - Street 1:17 BRIARWOOD LN
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2775
Practice Address - Country:US
Practice Address - Phone:207-233-5778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECADC CAC2971101YA0400X
MALICSW 1136691041C0700X
MELCSW LC72991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical