Provider Demographics
NPI:1689199895
Name:MIMANDE, AMANDA MARIE
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MARIE
Last Name:MIMANDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 SOUTH MAIN ST
Mailing Address - Street 2:APT 1A
Mailing Address - City:BROOKLYN
Mailing Address - State:CT
Mailing Address - Zip Code:06234
Mailing Address - Country:US
Mailing Address - Phone:860-341-6078
Mailing Address - Fax:
Practice Address - Street 1:162 WEST STREET
Practice Address - Street 2:BUILDING 2, SUITE F
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416
Practice Address - Country:US
Practice Address - Phone:860-613-9930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist