Healthcare Provider Details

I. General information

NPI: 1245327790
Provider Name (Legal Business Name): CYNTHIA AMBROGNE-OTOOLE LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 FOREST AVE
PORTLAND ME
04101-2006
US

IV. Provider business mailing address

343 FOREST AVE
PORTLAND ME
04101-2006
US

V. Phone/Fax

Practice location:
  • Phone: 207-874-1030
  • Fax: 207-874-1044
Mailing address:
  • Phone: 207-874-1030
  • Fax: 207-874-1044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLC652
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC463
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCC463
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: