Provider Demographics
NPI:1366729295
Name:HEBB, AMY NICOLE (PSYD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:NICOLE
Last Name:HEBB
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 1:65 PROFESSIONAL PLACE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330
Mailing Address - Country:US
Mailing Address - Phone:304-842-6463
Mailing Address - Fax:
Practice Address - Street 1:65 PROFESSIONAL PLACE
Practice Address - Street 2:SUITE 101
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330
Practice Address - Country:US
Practice Address - Phone:304-842-6463
Practice Address - Fax:304-842-8180
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-06
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1038103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810022680Medicaid