Basic Information
Provider Information | |||||||||
NPI: | 1578699930 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUTHRIE | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | KAY | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA, LP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1409 24TH ST | ||||||||
Address2: |   | ||||||||
City: | VIENNA | ||||||||
State: | WV | ||||||||
PostalCode: | 261052367 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3044221464 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2121 7TH ST | ||||||||
Address2: |   | ||||||||
City: | PARKERSBURG | ||||||||
State: | WV | ||||||||
PostalCode: | 261013803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3044851721 | ||||||||
FaxNumber: | 3044856710 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/27/2007 | ||||||||
LastUpdateDate: | 03/14/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TB0200X | 894 | WV | N |   | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC0700X | 894 | WV | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC1900X | 894 | WV | N |   | Behavioral Health & Social Service Providers | Psychologist | Counseling | 103TC2200X | 894 | WV | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103T00000X | 894 | WV | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 894 | 01 | WV | PSYCHOLOGY LICENSE | OTHER |