Healthcare Provider Details

I. General information

NPI: 1205665080
Provider Name (Legal Business Name): AMBER WILLWERTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 N MERIDIAN ST STE 100
SUNMAN IN
47041-7771
US

IV. Provider business mailing address

925 N MERIDIAN ST STE 100
SUNMAN IN
47041-7771
US

V. Phone/Fax

Practice location:
  • Phone: 812-623-2291
  • Fax:
Mailing address:
  • Phone: 812-623-2291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number000010619
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: