Provider Demographics
NPI:1750923975
Name:ELLIOTT, AMANDA (MA, LCPC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 CHRISTIAN RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605-3210
Mailing Address - Country:US
Mailing Address - Phone:207-610-9244
Mailing Address - Fax:
Practice Address - Street 1:52 CHRISTIAN RIDGE RD
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-3210
Practice Address - Country:US
Practice Address - Phone:207-667-5357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL5368101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MECC6953OtherSTATE OF MAINE