Provider Demographics
NPI:1972183499
Name:MAHNKE, AMANDA RUTH (PSYD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RUTH
Last Name:MAHNKE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 KENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2704
Mailing Address - Country:US
Mailing Address - Phone:202-680-0306
Mailing Address - Fax:
Practice Address - Street 1:625 MOUNT AUBURN ST STE 205A
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4530
Practice Address - Country:US
Practice Address - Phone:857-760-0210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA11733103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program