Provider Demographics
NPI:1780233445
Name:TARDY, AMY MARIE (PHD, LCPC, CCS, LADC)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MARIE
Last Name:TARDY
Suffix:
Gender:F
Credentials:PHD, LCPC, CCS, LADC
Other - Prefix:MRS
Other - First Name:AMY
Other - Middle Name:MARIE
Other - Last Name:CHERKASSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 1626
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04903-1626
Mailing Address - Country:US
Mailing Address - Phone:207-616-0499
Mailing Address - Fax:207-616-0227
Practice Address - Street 1:229B MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-6119
Practice Address - Country:US
Practice Address - Phone:207-578-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL5067101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional