Provider Demographics
NPI:1063097053
Name:AMY, TRUJILLO J (MRC, LPC, LVRC, CRC)
Entity type:Individual
Prefix:
First Name:TRUJILLO
Middle Name:J
Last Name:AMY
Suffix:
Gender:M
Credentials:MRC, LPC, LVRC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 S 450 W
Mailing Address - Street 2:
Mailing Address - City:HEYBURN
Mailing Address - State:ID
Mailing Address - Zip Code:83336-8693
Mailing Address - Country:US
Mailing Address - Phone:208-650-6961
Mailing Address - Fax:
Practice Address - Street 1:314 S 450 W
Practice Address - Street 2:
Practice Address - City:HEYBURN
Practice Address - State:ID
Practice Address - Zip Code:83336-8693
Practice Address - Country:US
Practice Address - Phone:208-650-6961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-7738101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional