Healthcare Provider Details

I. General information

NPI: 1720435530
Provider Name (Legal Business Name): AMBER GORS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2016
Last Update Date: 05/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7058 ROUTE 72 LOT 14
STILLMAN VALLEY IL
61084-9621
US

IV. Provider business mailing address

7058 ROUTE 72 LOT 14
STILLMAN VALLEY IL
61084-9621
US

V. Phone/Fax

Practice location:
  • Phone: 815-601-1119
  • Fax:
Mailing address:
  • Phone: 815-601-1119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: