Provider Demographics
NPI:1679084412
Name:BRASS, AMY S (EDS)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:S
Last Name:BRASS
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 N COLFAX ST
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:IL
Mailing Address - Zip Code:61010-1438
Mailing Address - Country:US
Mailing Address - Phone:815-234-2722
Mailing Address - Fax:
Practice Address - Street 1:417 N COLFAX ST
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:IL
Practice Address - Zip Code:61010-1438
Practice Address - Country:US
Practice Address - Phone:815-234-2722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1664082103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool