Provider Demographics
NPI:1447698501
Name:NUTTBROCK, AMY M (LICSW)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:M
Last Name:NUTTBROCK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660
Mailing Address - Country:US
Mailing Address - Phone:360-695-1014
Mailing Address - Fax:360-750-1374
Practice Address - Street 1:101 E 8TH ST STE 110
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-3294
Practice Address - Country:US
Practice Address - Phone:360-602-6842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-11
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL78351041C0700X
CALCSW796631041C0700X
WA609268831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical