Provider Demographics
NPI:1922631746
Name:BREW, AMY LYNN
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:BREW
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 1:15110 LAKETON AVE
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:MI
Mailing Address - Zip Code:49451-9714
Mailing Address - Country:US
Mailing Address - Phone:616-520-1636
Mailing Address - Fax:
Practice Address - Street 1:142 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CASNOVIA
Practice Address - State:MI
Practice Address - Zip Code:49318
Practice Address - Country:US
Practice Address - Phone:616-520-1636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501007390225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty