Provider Demographics
NPI:1992815278
Name:HOUSE, AMY S (PHD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:S
Last Name:HOUSE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1499 WALTON WAY
Mailing Address - Street 2:STE 1400
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2602
Mailing Address - Country:US
Mailing Address - Phone:706-828-8401
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-3141
Practice Address - Fax:706-721-6602
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002140103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0362Medicaid
GA000767665AMedicaid
GA68BBFLGMedicare ID - Type UnspecifiedGA MEDICARE #
SCPS0362Medicaid