Provider Demographics
NPI:1043376254
Name:KLINE, AMY ELLYN (PHD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:ELLYN
Last Name:KLINE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-3407
Mailing Address - Country:US
Mailing Address - Phone:530-666-7434
Mailing Address - Fax:530-666-7434
Practice Address - Street 1:720 MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-3407
Practice Address - Country:US
Practice Address - Phone:530-666-7434
Practice Address - Fax:530-666-7434
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15303103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY015303Medicaid
CAPSY015303Medicaid
CAOPL153030Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER