Provider Demographics
NPI:1114224417
Name:WELCH, AMY MARIE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:WELCH
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 1:503 FARRELL DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3775
Mailing Address - Country:US
Mailing Address - Phone:859-578-3204
Mailing Address - Fax:
Practice Address - Street 1:12 E 5TH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:KY
Practice Address - Zip Code:41071-1618
Practice Address - Country:US
Practice Address - Phone:859-781-5596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-22
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
KY2012-037106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7667OtherMEDI-CAL
KY610661458OtherTAX ID
CA7184OtherMEDI-CAL
CA7368OtherMEDI-CAL
CA7708OtherMEDI-CAL