Basic Information
| Provider Information | |||||||||
| NPI: | 1952429938 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GENTZ | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | CHRISTINE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRODESKI | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | CHRISTINE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW LCSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1736 EAST GATE PARKWAY | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154849952 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1969 W HART RD | ||||||||
| Address2: | |||||||||
| City: | BELOIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083645686 | ||||||||
| FaxNumber: | 6083635756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6961123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | IL | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.