Provider Demographics
NPI:1659573731
Name:BRAGDON, E. MERLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:E.
Middle Name:MERLE
Last Name:BRAGDON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS742103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME373948OtherVALUE OPTIONS
ME170033OtherANTHEM BCBS
MEE007054OtherCHAMPUS
MEE007054OtherCHAMPUS