Provider Demographics
NPI:1245751981
Name:MCCLAIN, AMY S (MDIV, MAMFT)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:S
Last Name:MCCLAIN
Suffix:
Gender:F
Credentials:MDIV, MAMFT
Other - Prefix:MS
Other - First Name:AMY
Other - Middle Name:S
Other - Last Name:MCCLAIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MDIV
Mailing Address - Street 1:2431 N PETERSON CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-2367
Mailing Address - Country:US
Mailing Address - Phone:502-457-7579
Mailing Address - Fax:
Practice Address - Street 1:4010 DUPONT CIR STE 582
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4888
Practice Address - Country:US
Practice Address - Phone:502-899-5477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-03
Last Update Date:2017-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY173338106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY173338OtherPRACTICE LICENSE