Healthcare Provider Details

I. General information

NPI: 1578426078
Provider Name (Legal Business Name): AMBER POORTENGA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14813 101ST AVENUE
DYER IN
46311
US

IV. Provider business mailing address

17506 CLINE ST
LOWELL IN
46356-2257
US

V. Phone/Fax

Practice location:
  • Phone: 219-245-7970
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: