Provider Demographics
NPI:1336549773
Name:STOFFREGEN, AMY LUITJOHAN (PSYD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LUITJOHAN
Last Name:STOFFREGEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 OLD HENDERSON RD STE 100D
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-3639
Mailing Address - Country:US
Mailing Address - Phone:614-547-7868
Mailing Address - Fax:
Practice Address - Street 1:1520 OLD HENDERSON RD STE 100D
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-3639
Practice Address - Country:US
Practice Address - Phone:614-456-7777
Practice Address - Fax:614-547-7868
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-03
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7196103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical