Basic Information
| Provider Information | |||||||||
| NPI: | 1497254841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | SAMARA | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OQMHP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CYR | ||||||||
| OtherFirstName: | SAMARA | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OQMHP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 180 ACADEMY ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | PRESQUE ISLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047693183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075542352 | ||||||||
| FaxNumber: | 2075542351 | ||||||||
| Practice Location | |||||||||
| Address1: | 43 HATCH DR STE 310 | ||||||||
| Address2: | |||||||||
| City: | CARIBOU | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047362002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074933361 | ||||||||
| FaxNumber: | 2074924889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2018 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.