Provider Demographics
NPI:1043078132
Name:LEESE, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:LEESE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3002 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-2321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3002 GRAND AVE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2321
Practice Address - Country:US
Practice Address - Phone:815-861-3603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060566221146L00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic