Provider Demographics
NPI:1104061605
Name:BURBAGE, AMY (PHD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BURBAGE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:COFFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11232 WOODS BAY LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-7601
Mailing Address - Country:US
Mailing Address - Phone:317-826-1082
Mailing Address - Fax:
Practice Address - Street 1:11232 WOODS BAY LN
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46236-7601
Practice Address - Country:US
Practice Address - Phone:317-826-1082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041902A103TC0700X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200953890Medicaid