Provider Demographics
NPI:1598069312
Name:E. MERLE BRAGDON, PHD, PA
Entity Type:Organization
Organization Name:E. MERLE BRAGDON, PHD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:E MERLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAGDON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:207-772-1570
Mailing Address - Street 1:178 MIDDLE ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4075
Mailing Address - Country:US
Mailing Address - Phone:207-772-1570
Mailing Address - Fax:207-772-2670
Practice Address - Street 1:178 MIDDLE ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4075
Practice Address - Country:US
Practice Address - Phone:207-772-1570
Practice Address - Fax:207-772-2670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-09
Last Update Date:2011-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS742103TC0700X
MEPS1124103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty