Healthcare Provider Details

I. General information

NPI: 1790698025
Provider Name (Legal Business Name): AMBER MARIE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2026
Last Update Date: 09/26/2026
Certification Date: 09/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 W MONTICELLO ST
BROOKHAVEN MS
39601-3209
US

IV. Provider business mailing address

519 W MONTICELLO ST
BROOKHAVEN MS
39601-3209
US

V. Phone/Fax

Practice location:
  • Phone: 601-822-2286
  • Fax: 601-822-2296
Mailing address:
  • Phone: 601-822-2286
  • Fax: 601-822-2296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: AMBER MARIE MARTIN
Title or Position: OWNER/THERAPIST
Credential: LPC
Phone: 601-822-2286