Healthcare Provider Details

I. General information

NPI: 1558926386
Provider Name (Legal Business Name): AMANDA KEDZIOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 05/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1844 WHITNEY AVE STE 2
HAMDEN CT
06517-1400
US

IV. Provider business mailing address

6 CASSELLA DR
WALLINGFORD CT
06492-1614
US

V. Phone/Fax

Practice location:
  • Phone: 203-407-1310
  • Fax: 203-407-1309
Mailing address:
  • Phone: 203-980-3307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number27-002084
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: