Provider Demographics
NPI:1518308360
Name:BRACKEN, AMY S (MS, ED, LPC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:S
Last Name:BRACKEN
Suffix:
Gender:F
Credentials:MS, ED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 N VANDEMARK RD
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-3567
Mailing Address - Country:US
Mailing Address - Phone:937-710-4616
Mailing Address - Fax:
Practice Address - Street 1:1059 N MARKET ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-1433
Practice Address - Country:US
Practice Address - Phone:937-335-4543
Practice Address - Fax:937-339-8371
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1100185101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0066745Medicaid