Provider Demographics
NPI:1861653859
Name:REPPOND, PHILLIP W (LCSW)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:W
Last Name:REPPOND
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 1:38 PLYMOUTH DR
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-1734
Mailing Address - Country:US
Mailing Address - Phone:207-282-4920
Mailing Address - Fax:707-598-1038
Practice Address - Street 1:38 PLYMOUTH DR
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-1734
Practice Address - Country:US
Practice Address - Phone:207-282-4920
Practice Address - Fax:707-598-1038
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELCS925101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432427399Medicaid