Healthcare Provider Details

I. General information

NPI: 1215874797
Provider Name (Legal Business Name): AMBER DANCE LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3920 S RURAL RD STE 112
TEMPE AZ
85282-5500
US

IV. Provider business mailing address

3920 S RURAL RD STE 112
TEMPE AZ
85282-5500
US

V. Phone/Fax

Practice location:
  • Phone: 480-428-2944
  • Fax:
Mailing address:
  • Phone: 480-428-2944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-24008
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: