=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386263937
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMBER ROSE TERRELL LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2020
-----------------------------------------------------
Last Update Date | 09/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17888 67TH CT N
-----------------------------------------------------
City | LOXAHATCHEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33470-3275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-830-7233
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4113 BARCLAY DR
-----------------------------------------------------
City | PACE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32571-2229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-288-7965
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 12786
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CSW.09929203
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW11863
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------