Provider Demographics
NPI:1477137826
Name:NULL, AMY MICHELLE
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:MICHELLE
Last Name:NULL
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 1:7542 SULPHUR SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:RAMER
Mailing Address - State:TN
Mailing Address - Zip Code:38367-5425
Mailing Address - Country:US
Mailing Address - Phone:731-610-0424
Mailing Address - Fax:
Practice Address - Street 1:275 COUNTY HIGHWAY 84
Practice Address - Street 2:
Practice Address - City:PHIL CAMPBELL
Practice Address - State:AL
Practice Address - Zip Code:35581-6509
Practice Address - Country:US
Practice Address - Phone:256-627-4032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18-60970106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician