Provider Demographics
NPI:1275934226
Name:ROE, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:ROE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:FAENZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 390
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-0390
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4906
Practice Address - Country:US
Practice Address - Phone:860-439-6400
Practice Address - Fax:860-390-1463
Is Sole Proprietor?:No
Enumeration Date:2014-09-09
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT101951041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical