Provider Demographics
NPI:1528220894
Name:SQUARE, AMANDA RAE (MD, MPH)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAE
Last Name:SQUARE
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:RAE
Other - Last Name:SANDOVAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:40 TEMPLE ST
Mailing Address - Street 2:SUITE 7C
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-2715
Mailing Address - Country:US
Mailing Address - Phone:203-785-2513
Mailing Address - Fax:
Practice Address - Street 1:40 TEMPLE ST
Practice Address - Street 2:SUITE 7C
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-2715
Practice Address - Country:US
Practice Address - Phone:203-785-2513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0500572084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2084D0003XMedicaid