Provider Demographics
NPI:1427475730
Name:RISLEY, AMANDA AVERY (LPC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:AVERY
Last Name:RISLEY
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 1:10 HIGGINS HWY STE 14
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-1437
Mailing Address - Country:US
Mailing Address - Phone:860-933-9937
Mailing Address - Fax:860-228-8106
Practice Address - Street 1:10 HIGGINS HWY STE 14
Practice Address - Street 2:
Practice Address - City:MANSFIELD CENTER
Practice Address - State:CT
Practice Address - Zip Code:06250-1437
Practice Address - Country:US
Practice Address - Phone:860-933-9937
Practice Address - Fax:860-228-8106
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-25
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003082101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional