Provider Demographics
NPI:1649658162
Name:D'AMBOISE, PATRICK ANDREW (LCPC)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:ANDREW
Last Name:D'AMBOISE
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 1:169 TOWN FARM RD
Mailing Address - Street 2:
Mailing Address - City:NEW GLOUCESTER
Mailing Address - State:ME
Mailing Address - Zip Code:04260-4435
Mailing Address - Country:US
Mailing Address - Phone:207-577-2666
Mailing Address - Fax:
Practice Address - Street 1:169 TOWN FARM RD
Practice Address - Street 2:
Practice Address - City:NEW GLOUCESTER
Practice Address - State:ME
Practice Address - Zip Code:04260-4435
Practice Address - Country:US
Practice Address - Phone:207-577-2666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-17
Last Update Date:2015-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC959101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor