Basic Information
| Provider Information | |||||||||
| NPI: | 1265528392 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HASHAM | ||||||||
| FirstName: | AMIE | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | QUIRION | ||||||||
| OtherFirstName: | AMIE | ||||||||
| OtherMiddleName: | LYN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CCS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 52 CHRISTIAN RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | ELLSWORTH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 046052116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076675357 | ||||||||
| FaxNumber: | 2072887024 | ||||||||
| Practice Location | |||||||||
| Address1: | 52 CHRISTIAN RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | ELLSWORTH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 046052116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076675357 | ||||||||
| FaxNumber: | 2072887024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 04/26/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LC10709 | ME | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | LC10709 | 01 | ME | MAINE LICENSE | OTHER | 411810099 | 05 | ME | MEDICAID |