Provider Demographics
NPI:1114275724
Name:EDENFIELD, AMBER KICKLIGHTER (LAPC)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:KICKLIGHTER
Last Name:EDENFIELD
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 N ANDERSON DR
Mailing Address - Street 2:P O BOX 1259
Mailing Address - City:SWAINSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30401-4440
Mailing Address - Country:US
Mailing Address - Phone:478-289-2683
Mailing Address - Fax:478-289-2522
Practice Address - Street 1:207 N ANDERSON DR
Practice Address - Street 2:
Practice Address - City:SWAINSBORO
Practice Address - State:GA
Practice Address - Zip Code:30401-4440
Practice Address - Country:US
Practice Address - Phone:478-289-2619
Practice Address - Fax:478-289-2622
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC003352101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional