Provider Demographics
NPI:1457615809
Name:BRUSH, AMY (MS ED)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BRUSH
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 E RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-3907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 E RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-3907
Practice Address - Country:US
Practice Address - Phone:716-307-7002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY20751OtherDEPARTMENT OF HEALTH