Basic Information
| Provider Information | |||||||||
| NPI: | 1134664238 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRYBUSH MARTIN | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LPCA, NCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 CLANTON RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282171309 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2208 W ROOSEVELT BLVD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281102762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042899869 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2016 | ||||||||
| LastUpdateDate: | 12/28/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | A12690 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.