Provider Demographics
NPI:1245372754
Name:PODGORSKI, AMY JO
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:JO
Last Name:PODGORSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 WOODSIDE DR
Mailing Address - Street 2:
Mailing Address - City:UNIONVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06085-1549
Mailing Address - Country:US
Mailing Address - Phone:860-404-0863
Mailing Address - Fax:
Practice Address - Street 1:91 NORTHWEST DR
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062-1534
Practice Address - Country:US
Practice Address - Phone:860-793-3849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT065320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities