Provider Demographics
NPI:1568105096
Name:DETAR, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:DETAR
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 1:937 N ROCKWELL AVE APT 64
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73127-5326
Mailing Address - Country:US
Mailing Address - Phone:405-408-0633
Mailing Address - Fax:
Practice Address - Street 1:4130 N LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-5209
Practice Address - Country:US
Practice Address - Phone:405-424-7711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health