Provider Demographics
NPI:1912054057
Name:JAMES-O'CONNOR, MARYBETH (LCSW)
Entity type:Individual
Prefix:
First Name:MARYBETH
Middle Name:
Last Name:JAMES-O'CONNOR
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 1:466 MAIN ST
Mailing Address - Street 2:SUITE #300
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-6748
Mailing Address - Country:US
Mailing Address - Phone:207-782-4209
Mailing Address - Fax:207-333-3296
Practice Address - Street 1:466 MAIN ST
Practice Address - Street 2:SUITE #300
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-6748
Practice Address - Country:US
Practice Address - Phone:207-782-4209
Practice Address - Fax:207-333-3291
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC21801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME211500000Medicaid
ME211500000Medicaid