Basic Information
Provider Information | |||||||||
NPI: | 1396332466 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAURIER | ||||||||
FirstName: | AMANDA | ||||||||
MiddleName: | JANE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LICSW, MLADC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX G | ||||||||
Address2: |   | ||||||||
City: | RANDOLPH | ||||||||
State: | VT | ||||||||
PostalCode: | 050600167 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8027284466 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10 MEMBERS WAY STE 201 | ||||||||
Address2: |   | ||||||||
City: | DOVER | ||||||||
State: | NH | ||||||||
PostalCode: | 038205933 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6037422263 | ||||||||
FaxNumber: | 6037407116 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/23/2020 | ||||||||
LastUpdateDate: | 02/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1185 | NH | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | EL05492 | NH | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 151.0134103 | VT | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | EL06575 | NH | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 2538 | NH | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.