Healthcare Provider Details

I. General information

NPI: 1871751834
Provider Name (Legal Business Name): AMITY HOPE OLMSTEAD LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 STATE ST
BANGOR ME
04401-5113
US

IV. Provider business mailing address

38 TYLER AVE
BANGOR ME
04401-3726
US

V. Phone/Fax

Practice location:
  • Phone: 207-200-1326
  • Fax:
Mailing address:
  • Phone: 207-200-1326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC3573
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: