Provider Demographics
NPI:1487203956
Name:GRANGER BAUGHMAN, AMBER RENEE
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:RENEE
Last Name:GRANGER BAUGHMAN
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 1:691 NW JEAN CT
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-7062
Mailing Address - Country:US
Mailing Address - Phone:386-965-5192
Mailing Address - Fax:
Practice Address - Street 1:691 NW JEAN CT
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-7062
Practice Address - Country:US
Practice Address - Phone:386-965-5192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-08
Last Update Date:2019-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12715101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health