Provider Demographics
NPI:1417572181
Name:BRUNO, AMY JO (PHD, NCSP)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:JO
Last Name:BRUNO
Suffix:
Gender:F
Credentials:PHD, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1913 W 19TH ST UNIT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-2647
Mailing Address - Country:US
Mailing Address - Phone:231-534-4341
Mailing Address - Fax:
Practice Address - Street 1:1913 W 19TH ST UNIT 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-2647
Practice Address - Country:US
Practice Address - Phone:231-534-4341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352000102103T00000X
IL071.010957103TC0700X, 103TC0700X
OHSP.00645103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool