Provider Demographics
NPI:1952429938
Name:GENTZ, AMY CHRISTINE (MSW LCSW)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:CHRISTINE
Last Name:GENTZ
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:MS
Other - First Name:AMY
Other - Middle Name:CHRISTINE
Other - Last Name:BRODESKI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW LCSW
Mailing Address - Street 1:1736 EAST GATE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108
Mailing Address - Country:US
Mailing Address - Phone:815-484-9952
Mailing Address - Fax:
Practice Address - Street 1:1969 W HART RD
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511
Practice Address - Country:US
Practice Address - Phone:608-364-5686
Practice Address - Fax:608-363-5756
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69611231041C0700X
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical