Provider Demographics
NPI:1245499177
Name:STASON, AMANDA (LMHC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:STASON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 SANDY POND RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:MA
Mailing Address - Zip Code:01773-2602
Mailing Address - Country:US
Mailing Address - Phone:617-947-7819
Mailing Address - Fax:
Practice Address - Street 1:111 OLD ROAD TO 9 ACRE COR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-4141
Practice Address - Country:US
Practice Address - Phone:978-369-1113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6435101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALMG085OtherBCBSMA