Provider Demographics
NPI:1093090433
Name:PONE, AMBER JOHNSON (LICSW)
Entity Type:Individual
Prefix:MS
First Name:AMBER
Middle Name:JOHNSON
Last Name:PONE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-3507
Mailing Address - Country:US
Mailing Address - Phone:512-363-6365
Mailing Address - Fax:
Practice Address - Street 1:212 RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-3507
Practice Address - Country:US
Practice Address - Phone:512-363-6365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-17
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN208771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical