Provider Demographics
NPI:1508401837
Name:O'BRYAN, AMY MARIE (LPC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:O'BRYAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 WALNUT POINT DR
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-1559
Mailing Address - Country:US
Mailing Address - Phone:404-786-0704
Mailing Address - Fax:
Practice Address - Street 1:1020 CREWS RD STE M
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-7587
Practice Address - Country:US
Practice Address - Phone:704-807-6555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11654101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC11654OtherLPC