Provider Demographics
NPI:1457595290
Name:MERRIAM, PHYLLIS (LCSW)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:MERRIAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 MECHANIC ST
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04841-3514
Mailing Address - Country:US
Mailing Address - Phone:207-594-0947
Mailing Address - Fax:
Practice Address - Street 1:247 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-5964
Practice Address - Country:US
Practice Address - Phone:207-470-7090
Practice Address - Fax:207-470-7094
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC11515101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health