Provider Demographics
NPI:1043871817
Name:MCDERMOTT, AMANDA (MSED, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:MSED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 BOSTON POST RD UNIT 63
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1967
Mailing Address - Country:US
Mailing Address - Phone:203-243-3203
Mailing Address - Fax:
Practice Address - Street 1:1842 MERIDEN-WATERBURY TURNPIKE
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489
Practice Address - Country:US
Practice Address - Phone:203-313-5537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1-19-34879103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst