Provider Demographics
NPI:1154610285
Name:SHUTE, AMY LEE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:LEE
Last Name:SHUTE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:AMY
Other - Middle Name:LEE
Other - Last Name:BURLESON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:115 STILLHOUSE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6943
Mailing Address - Country:US
Mailing Address - Phone:601-291-1010
Mailing Address - Fax:
Practice Address - Street 1:2240 WESTBROOK RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-4900
Practice Address - Country:US
Practice Address - Phone:601-957-7373
Practice Address - Fax:601-957-7372
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-29
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC28681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS62209Medicaid