Provider Demographics
NPI:1679676480
Name:WINE, AMY MARGARET (LISW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARGARET
Last Name:WINE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2485 TECH DR
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-3262
Mailing Address - Country:US
Mailing Address - Phone:563-355-1611
Mailing Address - Fax:563-355-6617
Practice Address - Street 1:2485 TECH DR
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-3262
Practice Address - Country:US
Practice Address - Phone:563-355-1611
Practice Address - Fax:563-355-6617
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA05946104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0283507Medicaid
IAI8118Medicare ID - Type Unspecified