Provider Demographics
NPI:1508875915
Name:SIMONDS, CHARLES SPRAGUE JR (PSYD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:SPRAGUE
Last Name:SIMONDS
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 ANDOVER RD
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04092-3848
Mailing Address - Country:US
Mailing Address - Phone:207-761-2200
Mailing Address - Fax:207-842-7773
Practice Address - Street 1:123 ANDOVER RD
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-3848
Practice Address - Country:US
Practice Address - Phone:207-761-2200
Practice Address - Fax:207-842-7773
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1074103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME1097Medicare ID - Type UnspecifiedMEDICARE B