Provider Demographics
NPI:1568528610
Name:ABBOTT, SAMUEL ANDERSON (LCPC)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:ANDERSON
Last Name:ABBOTT
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 MACKWORTH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-4532
Mailing Address - Country:US
Mailing Address - Phone:207-831-8561
Mailing Address - Fax:
Practice Address - Street 1:686 BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-1012
Practice Address - Country:US
Practice Address - Phone:207-831-8561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC2662101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional