Provider Demographics
NPI:1154216828
Name:BACON, AMY MARIE (LAPC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:BACON
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 WILCOX ST
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:PA
Mailing Address - Zip Code:16417-1340
Mailing Address - Country:US
Mailing Address - Phone:814-218-5194
Mailing Address - Fax:
Practice Address - Street 1:4380 W 12TH ST STE 2F
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-3028
Practice Address - Country:US
Practice Address - Phone:814-580-6166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-11
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAPC001309101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health