1154610285 NPI number — MRS. AMY LEE SHUTE LCSW

Table of content: MRS. AMY LEE SHUTE LCSW (NPI 1154610285)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154610285 NPI number — MRS. AMY LEE SHUTE LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHUTE
Provider First Name:
AMY
Provider Middle Name:
LEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BURLESON
Provider Other First Name:
AMY
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1154610285
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 STILLHOUSE CREEK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39110-6943
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-291-1010
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2240 WESTBROOK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39211-4900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-957-7373
Provider Business Practice Location Address Fax Number:
601-957-7372
Provider Enumeration Date:
03/29/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  C2868 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 62209 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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