Provider Demographics
NPI:1972162014
Name:SHOOK, AMY (LCDC III)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:SHOOK
Suffix:
Gender:F
Credentials:LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9083 MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:38882 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-7875
Practice Address - Country:US
Practice Address - Phone:440-578-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHLCDCIII.162497101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator