Provider Demographics
NPI:1679641336
Name:ROBERTS, AMY LYNN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:LYNN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2920 S LEADVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-4742
Mailing Address - Country:US
Mailing Address - Phone:208-869-3857
Mailing Address - Fax:
Practice Address - Street 1:1276 W RIVER ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7066
Practice Address - Country:US
Practice Address - Phone:208-338-4699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-25145101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDL4736OtherBLUE CROSS
ID000010144896OtherBLUE SHIELD
ID002803300Medicaid