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NPI Code Detail

MEDICARE: AMBER BROADWAY LPE

MEDICARE: AMBER BROADWAY LPE
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor04-01EAR

General Provider Information

NPI Number : 1184787749
Entity Type Code : Individual
Provider Name (Legal Business Name) : AMBER BROADWAY LPE
Provider Business Mailing Address
First Line : 2411 W MAIN ST
Second Line :
City : JACKSONVILLE
State : AR
Zip : 72076-4211
Country : US
Telephone Number : 501-982-5402
Fax Number : 501-982-5404
Provider Business Practice Location Address
First Line : 2411 W MAIN ST
Second Line :
City : JACKSONVILLE
State : AR
Zip : 72076-4211
Country : US
Telephone Number : 501-982-5402
Fax Number : 501-982-5404
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/18/2006
Last Update Date : 07/08/2007

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Directions to “ AMBER BROADWAY LPE” Practice Location

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