=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316725013
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMBER STONE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2023
-----------------------------------------------------
Last Update Date | 09/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 147 SW COURT ST
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97338-3112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-304-4358
-----------------------------------------------------
Fax | 503-304-4361
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 20674
-----------------------------------------------------
City | KEIZER
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97307-0674
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-304-4358
-----------------------------------------------------
Fax | 503-304-4361
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | T-23-2780
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------