Provider Demographics
NPI:1871919365
Name:DIBIASIE, AMANDA LENA-MARLOW (LMFT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LENA-MARLOW
Last Name:DIBIASIE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 N LINE RD STE 5
Mailing Address - Street 2:
Mailing Address - City:WOLFEBORO
Mailing Address - State:NH
Mailing Address - Zip Code:03894-4512
Mailing Address - Country:US
Mailing Address - Phone:617-413-1352
Mailing Address - Fax:
Practice Address - Street 1:70 COMMERCIAL ST STE 200
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-5094
Practice Address - Country:US
Practice Address - Phone:617-413-1352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-09
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH266106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist