Provider Demographics
NPI:1376736579
Name:EVANS POWELL, AMANDA S (LCSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:EVANS POWELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 CUMMINGS AVE
Mailing Address - Street 2:
Mailing Address - City:BUXTON
Mailing Address - State:ME
Mailing Address - Zip Code:04093
Mailing Address - Country:US
Mailing Address - Phone:207-650-0625
Mailing Address - Fax:
Practice Address - Street 1:1577 CONGRESS ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2169
Practice Address - Country:US
Practice Address - Phone:207-662-1622
Practice Address - Fax:207-774-1814
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELS8751104100000X
MELC121591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30427534Medicaid
ME432649799Medicaid
ME001213401Medicare PIN