Healthcare Provider Details

I. General information

NPI: 1689502742
Provider Name (Legal Business Name): NINO MAMUKASHVILI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BRIDGEPORT AVE STE 405
SHELTON CT
06484-4660
US

IV. Provider business mailing address

8 JUNE AVE
NORWALK CT
06850-2535
US

V. Phone/Fax

Practice location:
  • Phone: 203-993-6592
  • Fax: 475-203-3328
Mailing address:
  • Phone: 475-283-4141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: