Provider Demographics
NPI:1740521855
Name:ADCOCK, AMANDA C (PHD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:C
Last Name:ADCOCK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:AMANDA
Other - Middle Name:ADCOCK
Other - Last Name:VANDERLUGT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 63
Mailing Address - Street 2:
Mailing Address - City:GARDINER
Mailing Address - State:ME
Mailing Address - Zip Code:04345-0063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 VA CTR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-6719
Practice Address - Country:US
Practice Address - Phone:207-623-8411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1379103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical