Provider Demographics
NPI:1093220139
Name:MAKICE, AMY C (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:C
Last Name:MAKICE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 S PALMER AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5955
Mailing Address - Country:US
Mailing Address - Phone:812-325-7513
Mailing Address - Fax:
Practice Address - Street 1:315 W DODDS ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2510
Practice Address - Country:US
Practice Address - Phone:812-669-2227
Practice Address - Fax:812-669-2227
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004062A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical