Healthcare Provider Details

I. General information

NPI: 1992510606
Provider Name (Legal Business Name): TYLER-ANN AMAMGBO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2025
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 SHERBROOKE RD
EWING NJ
08638-2416
US

IV. Provider business mailing address

31 SHERBROOKE RD
EWING NJ
08638-2416
US

V. Phone/Fax

Practice location:
  • Phone: 786-376-3666
  • Fax:
Mailing address:
  • Phone: 786-376-3666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number099476
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: