Provider Demographics
NPI:1942754247
Name:ROBITAILLE, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ROBITAILLE
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 1:345A GREENWOOD STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01607-1767
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:345A GREENWOOD STREET
Practice Address - Street 2:SUITE B
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01607-1767
Practice Address - Country:US
Practice Address - Phone:508-363-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-04
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
MA11623240103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist