Provider Demographics
NPI:1891108650
Name:SMITH, AMANDA J (LPC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:SMITH
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 1:325 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06480-1561
Mailing Address - Country:US
Mailing Address - Phone:860-342-3252
Mailing Address - Fax:
Practice Address - Street 1:325 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:CT
Practice Address - Zip Code:06480-1561
Practice Address - Country:US
Practice Address - Phone:860-342-3252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005398101YP2500X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional