Healthcare Provider Details

I. General information

NPI: 1376207324
Provider Name (Legal Business Name): AMANDA CIMAGLIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2021
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 FAIRFIELD WAY STE 380
BLOOMINGDALE IL
60108-3701
US

IV. Provider business mailing address

125 FAIRFIELD WAY STE 380
BLOOMINGDALE IL
60108-3701
US

V. Phone/Fax

Practice location:
  • Phone: 815-295-5470
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178017510
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: