Healthcare Provider Details

I. General information

NPI: 1407567472
Provider Name (Legal Business Name): AMBER SEWELL LMHCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2022
Last Update Date: 12/09/2022
Certification Date: 12/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4630 W JEFFERSON BLVD STE 3
FORT WAYNE IN
46804-6800
US

IV. Provider business mailing address

5820 N SHORE DR
LEO IN
46765-9557
US

V. Phone/Fax

Practice location:
  • Phone: 260-349-2397
  • Fax:
Mailing address:
  • Phone: 260-349-2397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number99115602A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: