Provider Demographics
NPI:1376605808
Name:HERTLE, AMY BETH (LICSW, LP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:BETH
Last Name:HERTLE
Suffix:
Gender:F
Credentials:LICSW, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2095 SPRUCE PL
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-4731
Mailing Address - Country:US
Mailing Address - Phone:651-890-6031
Mailing Address - Fax:
Practice Address - Street 1:3570 LEXINGTON AVE N
Practice Address - Street 2:SUITE 100
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-8049
Practice Address - Country:US
Practice Address - Phone:651-481-0664
Practice Address - Fax:651-481-3907
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2019-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN149041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN968115900Medicaid
MNHP57337OtherHEALTH PARTNERS LEGACY ID