Healthcare Provider Details

I. General information

NPI: 1225436934
Provider Name (Legal Business Name): MRS. AMY SHIVER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2014
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 DOUGLAS DR
BAINBRIDGE GA
39819-5245
US

IV. Provider business mailing address

1901 DOUGLAS DR
BAINBRIDGE GA
39819-5245
US

V. Phone/Fax

Practice location:
  • Phone: 435-574-9182
  • Fax:
Mailing address:
  • Phone: 435-574-9182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC06629
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: