Provider Demographics
NPI:1164159786
Name:SUMBRY-HASLETT, AMBER SAMIRAH
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:SAMIRAH
Last Name:SUMBRY-HASLETT
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 1:100 GOVERNORS TRCE STE 101
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-4853
Mailing Address - Country:US
Mailing Address - Phone:770-268-2520
Mailing Address - Fax:
Practice Address - Street 1:100 GOVERNORS TRCE STE 101
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-4853
Practice Address - Country:US
Practice Address - Phone:770-268-2520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-22-209178106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician