=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982327805
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMISTAD, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2022
-----------------------------------------------------
Last Update Date | 09/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 INDIA ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04101-4211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-773-1956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 INDIA ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04101-4211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-773-1956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | BRIAN TOWNSEND
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 207-773-1956
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------