=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518215987
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMBER BANE SENERES LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2012
-----------------------------------------------------
Last Update Date | 02/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1241 N ROAD ST
-----------------------------------------------------
City | ELIZABETH CITY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27909-3335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-500-0534
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 161 PELICAN POINTE DR
-----------------------------------------------------
City | ELIZABETH CITY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27909-7763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-619-5451
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 9442
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------