Provider Demographics
NPI:1366930406
Name:BRUYN, AMY (LCPC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BRUYN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6392 LINDEN RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61109-2816
Mailing Address - Country:US
Mailing Address - Phone:779-368-0060
Mailing Address - Fax:
Practice Address - Street 1:6392 LINDEN RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61109-2816
Practice Address - Country:US
Practice Address - Phone:779-368-0060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178-013197101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional