Basic Information
| Provider Information | |||||||||
| NPI: | 1447564299 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOGARTY | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | AARRON | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 166 GARLAND ST APT 2 | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044020936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079492526 | ||||||||
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| Practice Location | |||||||||
| Address1: | 81 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044016259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076312201 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2010 | ||||||||
| LastUpdateDate: | 03/27/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | XL3677 | ME | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.