Healthcare Provider Details

I. General information

NPI: 1629990528
Provider Name (Legal Business Name): AMI FORMICA MA, LPCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

497 SW CENTURY DR STE 102
BEND OR
97702-1167
US

IV. Provider business mailing address

497 SW CENTURY DR STE 102
BEND OR
97702-1167
US

V. Phone/Fax

Practice location:
  • Phone: 201-233-0293
  • Fax:
Mailing address:
  • Phone: 201-233-0293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberR9764
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: