Provider Demographics
NPI:1558799874
Name:HEBERLE, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:HEBERLE
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 1:950 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610-1400
Mailing Address - Country:US
Mailing Address - Phone:937-638-2336
Mailing Address - Fax:
Practice Address - Street 1:950 MAIN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-1400
Practice Address - Country:US
Practice Address - Phone:937-638-2336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-23
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA10980103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program