Provider Demographics
NPI:1598178865
Name:NOWAK, AMANDA JEAN (LPC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:NOWAK
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:PO BOX 633
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-0633
Mailing Address - Country:US
Mailing Address - Phone:860-926-0142
Mailing Address - Fax:860-413-0919
Practice Address - Street 1:134 MAIN ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1920
Practice Address - Country:US
Practice Address - Phone:860-926-0142
Practice Address - Fax:860-413-0919
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003392101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004040564Medicaid