Provider Demographics
NPI:1740445147
Name:AVERY, JILL ELLEN BISHOP (LCSW)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:ELLEN BISHOP
Last Name:AVERY
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 1:418 WATER ST
Mailing Address - Street 2:
Mailing Address - City:GARDINER
Mailing Address - State:ME
Mailing Address - Zip Code:04345-2058
Mailing Address - Country:US
Mailing Address - Phone:207-588-0235
Mailing Address - Fax:
Practice Address - Street 1:418 WATER ST
Practice Address - Street 2:
Practice Address - City:GARDINER
Practice Address - State:ME
Practice Address - Zip Code:04345-2058
Practice Address - Country:US
Practice Address - Phone:207-588-0235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC116401041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker