Healthcare Provider Details

I. General information

NPI: 1093350969
Provider Name (Legal Business Name): VICTORIA AMBORT LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 ALCOA RD
BENTON AR
72015-3420
US

IV. Provider business mailing address

1201 MILITARY RD STE 1
BENTON AR
72015-2922
US

V. Phone/Fax

Practice location:
  • Phone: 501-352-1359
  • Fax: 501-325-1919
Mailing address:
  • Phone: 501-352-1359
  • Fax: 501-325-1919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP2511015
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: