Healthcare Provider Details

I. General information

NPI: 1508608654
Provider Name (Legal Business Name): AMBER DISE PSYCHIATRY AND WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2024
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9524 WORKHOUSE RD RM 402
LORTON VA
22079-2641
US

IV. Provider business mailing address

12572 PLYMOUTH CT
WOODBRIDGE VA
22192-2321
US

V. Phone/Fax

Practice location:
  • Phone: 571-398-9278
  • Fax:
Mailing address:
  • Phone: 703-498-7684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. AMBER NICOLE ANTOINNETTE DISE
Title or Position: NURSE PRACTITIONER
Credential: DNP, PMHNP-BC
Phone: 571-398-9278