Healthcare Provider Details

I. General information

NPI: 1366048340
Provider Name (Legal Business Name): AMBER WITHERSPOON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 W BURLEIGH ST
MILWAUKEE WI
53210-1516
US

IV. Provider business mailing address

5800 W BURLEIGH ST
MILWAUKEE WI
53210-1516
US

V. Phone/Fax

Practice location:
  • Phone: 414-563-7229
  • Fax: 414-238-9511
Mailing address:
  • Phone: 414-563-7229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9213-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: