Provider Demographics
NPI:1922219096
Name:DUBORD, EDITH T (LCSW, LADC)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:T
Last Name:DUBORD
Suffix:
Gender:F
Credentials:LCSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 EMU ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-6037
Mailing Address - Country:US
Mailing Address - Phone:207-865-6862
Mailing Address - Fax:207-865-0597
Practice Address - Street 1:30 FOREST FALLS DR STE 1
Practice Address - Street 2:
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096-6983
Practice Address - Country:US
Practice Address - Phone:207-712-6739
Practice Address - Fax:207-865-0597
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC3971101YA0400X
MELC108131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical