Provider Demographics
NPI:1235529249
Name:GERVASIO, AMY HERSTEIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:HERSTEIN
Last Name:GERVASIO
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 1:2324 DIXON ST
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-3939
Mailing Address - Country:US
Mailing Address - Phone:715-254-5843
Mailing Address - Fax:
Practice Address - Street 1:1052 MAIN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-2848
Practice Address - Country:US
Practice Address - Phone:715-254-5843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2201-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical