Provider Demographics
NPI:1285077818
Name:BAILEY, AMANDA (LCPC-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BAILEY
Suffix:
Gender:F
Credentials:LCPC-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 EASTLAWN RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1912
Mailing Address - Country:US
Mailing Address - Phone:207-749-7970
Mailing Address - Fax:
Practice Address - Street 1:222 SAINT JOHN ST
Practice Address - Street 2:SUITE 118
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3000
Practice Address - Country:US
Practice Address - Phone:207-749-7970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-13
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL4015101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional