Provider Demographics
NPI:1164039244
Name:KENWORTHY-BYERS, AMBERDAWN E
Entity Type:Individual
Prefix:
First Name:AMBERDAWN
Middle Name:E
Last Name:KENWORTHY-BYERS
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 1:3746 HICKORY LN
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45331-3014
Mailing Address - Country:US
Mailing Address - Phone:937-547-1934
Mailing Address - Fax:
Practice Address - Street 1:3746 HICKORY LN
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-3014
Practice Address - Country:US
Practice Address - Phone:937-547-1934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities