Provider Demographics
NPI:1083215719
Name:SIDERS, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:SIDERS
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 1:248 RED OAKS SHOPPING CENTER
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801
Mailing Address - Country:US
Mailing Address - Phone:304-645-6226
Mailing Address - Fax:304-645-9850
Practice Address - Street 1:248 RED OAKS SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-1349
Practice Address - Country:US
Practice Address - Phone:304-645-6226
Practice Address - Fax:304-645-9850
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator