Provider Demographics
NPI:1891027785
Name:SPELLERBERG MASSIE, AMY M (LISW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:SPELLERBERG MASSIE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:M
Other - Last Name:SPELLERBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:1441 W CENTRAL PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52804-1707
Mailing Address - Country:US
Mailing Address - Phone:563-383-1900
Mailing Address - Fax:563-884-4638
Practice Address - Street 1:1441 W CENTRAL PARK AVE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-1707
Practice Address - Country:US
Practice Address - Phone:563-383-1900
Practice Address - Fax:563-884-4638
Is Sole Proprietor?:No
Enumeration Date:2010-02-03
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0070331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA420716337OtherEIN