Provider Demographics
NPI:1043965411
Name:WIRAG, AMANDA (LPC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WIRAG
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 SQUASH HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776-5403
Mailing Address - Country:US
Mailing Address - Phone:203-460-0584
Mailing Address - Fax:
Practice Address - Street 1:54 SQUASH HOLLOW RD
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776-5403
Practice Address - Country:US
Practice Address - Phone:203-460-0584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-15
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5401101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional