Provider Demographics
NPI:1619203973
Name:EDELBERG, JERROLD C (PHD)
Entity type:Individual
Prefix:DR
First Name:JERROLD
Middle Name:C
Last Name:EDELBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280B GANNETT DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6940
Mailing Address - Country:US
Mailing Address - Phone:207-828-0048
Mailing Address - Fax:207-772-3743
Practice Address - Street 1:280B GANNETT DR
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-6940
Practice Address - Country:US
Practice Address - Phone:207-828-0048
Practice Address - Fax:207-772-3743
Is Sole Proprietor?:No
Enumeration Date:2009-10-21
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS561103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1053467779Medicaid