Provider Demographics
NPI:1497116875
Name:VITACOLONNA, AMY (BS)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:VITACOLONNA
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MARY
Other - Last Name:MYRFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LMHC
Mailing Address - Street 1:144 TIMBERLAKE DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-9309
Mailing Address - Country:US
Mailing Address - Phone:360-349-8775
Mailing Address - Fax:
Practice Address - Street 1:144 TIMBERLAKE DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-9309
Practice Address - Country:US
Practice Address - Phone:360-349-8775
Practice Address - Fax:843-897-0100
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-14
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
WALH60943631101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA85-2743925OtherIRS
SC8246OtherSOUTH CAROLINA LICENSING BOARD FOR COUNSELORS
WALH60943631OtherWASHINGTON STATE DEPARTMENT OF HEALTH