Provider Demographics
NPI:1912206400
Name:HORNBACK, AMY ELIZABETH (RSS)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH
Last Name:HORNBACK
Suffix:
Gender:F
Credentials:RSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 S COMMERCE ST BLDG B
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-5519
Mailing Address - Country:US
Mailing Address - Phone:580-223-5636
Mailing Address - Fax:580-226-6727
Practice Address - Street 1:2530 S COMMERCE ST
Practice Address - Street 2:BUILDING B
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-5519
Practice Address - Country:US
Practice Address - Phone:580-223-5636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health