Basic Information
| Provider Information | |||||||||
| NPI: | 1447698501 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NUTTBROCK | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1014 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606951014 | ||||||||
| FaxNumber: | 3607501374 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 E 8TH ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986603294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606026842 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2013 | ||||||||
| LastUpdateDate: | 09/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | L7835 | OR | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LCSW79663 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 60926883 | WA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.