Healthcare Provider Details

I. General information

NPI: 1437545779
Provider Name (Legal Business Name): AMANDA LYNN BLOKING
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 06/15/2022
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 FARMINGTON AVE
WEST HARTFORD CT
06107-2181
US

IV. Provider business mailing address

1013 FARMINGTON AVE
WEST HARTFORD CT
06107-2181
US

V. Phone/Fax

Practice location:
  • Phone: 860-236-9004
  • Fax:
Mailing address:
  • Phone: 860-830-2626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number1695
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: