Provider Demographics
NPI:1174991681
Name:DIBIASE, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:DIBIASE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 SHAKER RD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:GRAY
Mailing Address - State:ME
Mailing Address - Zip Code:04039-9640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:67 SHAKER RD
Practice Address - Street 2:SUITE 7
Practice Address - City:GRAY
Practice Address - State:ME
Practice Address - Zip Code:04039-9640
Practice Address - Country:US
Practice Address - Phone:207-657-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-14
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC149781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical