Provider Demographics
NPI:1538158159
Name:WASHINGTON COUNTY PSYCHOTHERAPY ASSOCIATES, PA
Entity type:Organization
Organization Name:WASHINGTON COUNTY PSYCHOTHERAPY ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:207-255-4990
Mailing Address - Street 1:294 E. KENNEBEC RD.
Mailing Address - Street 2:
Mailing Address - City:MACHIAS
Mailing Address - State:ME
Mailing Address - Zip Code:04654
Mailing Address - Country:US
Mailing Address - Phone:207-255-4990
Mailing Address - Fax:
Practice Address - Street 1:1 STACKPOLE RD
Practice Address - Street 2:
Practice Address - City:MACHIAS
Practice Address - State:ME
Practice Address - Zip Code:04654
Practice Address - Country:US
Practice Address - Phone:207-255-0996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-17
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME354881101Y00000X, 103T00000X, 104100000X
ME401871101YA0400X
ME229841103G00000X, 103T00000X, 104100000X, 106H00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME119790202Medicaid
ME119790102Medicaid
ME119790106Medicaid
ME119790105Medicaid
ME119790001Medicaid
ME119790000Medicaid
ME119790200Medicaid
ME119790201Medicaid
MEMM7660Medicare ID - Type UnspecifiedPSYCHIATRY GROUP NUMBER
ME119790202Medicaid
ME119790001Medicaid