Healthcare Provider Details

I. General information

NPI: 1528989027
Provider Name (Legal Business Name): AVA ELISE AMENDOLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 MAIN ST
GLASTONBURY CT
06033-2218
US

IV. Provider business mailing address

98 FAIRWAY DR
PORTLAND CT
06480-1600
US

V. Phone/Fax

Practice location:
  • Phone: 860-430-1762
  • Fax:
Mailing address:
  • Phone: 860-899-5761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2338
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: