Provider Demographics
NPI:1124577143
Name:WARREN, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:WARREN
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 1:20 LAKE WIRE DR
Mailing Address - Street 2:250
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33815-1519
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 LAKE WIRE DR
Practice Address - Street 2:250
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33815-1519
Practice Address - Country:US
Practice Address - Phone:863-937-9650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH12626101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health