Healthcare Provider Details

I. General information

NPI: 1689199895
Provider Name (Legal Business Name): MRS. AMANDA MARIE MIMANDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2017
Last Update Date: 08/28/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54-56 BOSTON POST RD
WILLIMANTIC CT
06226
US

IV. Provider business mailing address

52 PERRY HILL RD APT 3F
ASHFORD CT
06278-1028
US

V. Phone/Fax

Practice location:
  • Phone: 860-456-7990
  • Fax:
Mailing address:
  • Phone: 860-341-6078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: