Healthcare Provider Details

I. General information

NPI: 1649069956
Provider Name (Legal Business Name): AMBER DANIELLE CHUDZIK LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2025
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18001 N 79TH AVE
GLENDALE AZ
85308-8388
US

IV. Provider business mailing address

27106 N 97TH LN
PEORIA AZ
85383-8799
US

V. Phone/Fax

Practice location:
  • Phone: 480-269-1562
  • Fax:
Mailing address:
  • Phone: 602-326-1378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-18746
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: