1427308709 NPI number — MS. BLYTHE ELLEN EDWARDS MS, LCPC-C

Table of content: MS. BLYTHE ELLEN EDWARDS MS, LCPC-C (NPI 1427308709)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427308709 NPI number — MS. BLYTHE ELLEN EDWARDS MS, LCPC-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDWARDS
Provider First Name:
BLYTHE
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS, LCPC-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427308709
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
899 RIVERSIDE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04103-1070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-871-1211
Provider Business Mailing Address Fax Number:
207-871-1232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
220 DANVILLE CORNER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04210-8605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-956-3346
Provider Business Practice Location Address Fax Number:
207-871-1232
Provider Enumeration Date:
09/14/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  XL3966 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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