Healthcare Provider Details

I. General information

NPI: 1164943700
Provider Name (Legal Business Name): AMBER MARIE WESTPHAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 07/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6302 13TH AVENUE
LUCERNE CA
95458
US

IV. Provider business mailing address

4466 CEDAR AVENUE
CLEARLAKE CA
95422
US

V. Phone/Fax

Practice location:
  • Phone: 707-274-9101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10456-R
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: