Provider Demographics
NPI:1124244751
Name:SHULL, AMY LYNNE (MFT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LYNNE
Last Name:SHULL
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7501 HORSECHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:CO
Mailing Address - Zip Code:80549-2091
Mailing Address - Country:US
Mailing Address - Phone:650-504-0539
Mailing Address - Fax:
Practice Address - Street 1:1006 ROBERTSON ST STE 110
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3948
Practice Address - Country:US
Practice Address - Phone:650-504-0539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14371101YP2500X
CO1500106H00000X
CO0001500101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO62984853Medicaid