Provider Demographics
NPI:1073195962
Name:LOSK, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:LOSK
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 1:680 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-3825
Mailing Address - Country:US
Mailing Address - Phone:707-241-3007
Mailing Address - Fax:
Practice Address - Street 1:680 WILSON AVE
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-3825
Practice Address - Country:US
Practice Address - Phone:707-241-3007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-21
Last Update Date:2024-03-29
Deactivation Date:2021-06-09
Deactivation Code:
Reactivation Date:2021-06-25
Provider Licenses
StateLicense IDTaxonomies
CA120975106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
120975OtherLMFT BBS