Provider Demographics
NPI:1538867122
Name:RUTHERFORD, AMY (M ED, LPC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:RUTHERFORD
Suffix:
Gender:F
Credentials:M ED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-6801
Mailing Address - Country:US
Mailing Address - Phone:325-947-5021
Mailing Address - Fax:325-267-2629
Practice Address - Street 1:3131 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-6801
Practice Address - Country:US
Practice Address - Phone:325-947-5021
Practice Address - Fax:325-267-2629
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-22
Last Update Date:2024-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX84390101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84390OtherLICENSED PROFESSIONAL COUNSELOR