Provider Demographics
NPI:1205904430
Name:BROOKS DEWEESE, AMY E (PHD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:E
Last Name:BROOKS DEWEESE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:E
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1333 IRIS AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-2226
Mailing Address - Country:US
Mailing Address - Phone:303-443-8500
Mailing Address - Fax:
Practice Address - Street 1:1333 IRIS AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-2226
Practice Address - Country:US
Practice Address - Phone:303-443-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002046103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
S42301Medicare UPIN
68BBGKBMedicare ID - Type Unspecified