Provider Demographics
NPI:1902915895
Name:RODERICK, MARGARETHE L (LCSW)
Entity Type:Individual
Prefix:
First Name:MARGARETHE
Middle Name:L
Last Name:RODERICK
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 1:100 GANNETT DR STE C
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5900
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:100 FODEN RD. WEST
Practice Address - Street 2:SUITE 303
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2327
Practice Address - Country:US
Practice Address - Phone:207-523-3767
Practice Address - Fax:207-523-8596
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC55961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM5917Medicare PIN
MEMM591701Medicare PIN