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General NPI Number Information
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NPI Number | 1770925018
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Entity Type | Individual
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Provider Name | AMANDA GAIL WHITACRE PH.D.
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Gender | Female
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Dates
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Enumeration Date | 07/29/2013
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Last Update Date | 09/17/2020
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Provider Practice Location Address
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Address Line | 1200 HIGH RIDGE RD
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City | STAMFORD
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State | CT
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Zip | 06905-1223
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Country | US
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Telephone | 203-580-3595
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Fax |
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Provider Business Mailing Address
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Address Line | 264 SOUND BEACH AVE APT 2N
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City | OLD GREENWICH
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State | CT
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Zip | 06870-1614
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Country | US
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Telephone | 203-940-3595
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 003916
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License Number State | CT
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