Healthcare Provider Details

I. General information

NPI: 1649863861
Provider Name (Legal Business Name): AMBER VANDERBEEK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2021
Last Update Date: 04/21/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 E MAPLE ST
HAILEY ID
83333-4900
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-788-3200
  • Fax:
Mailing address:
  • Phone:
  • Fax: 716-332-2820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number00106959
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-43234
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: