Provider Demographics
NPI:1568192540
Name:WANG, AMBER (IS)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:IS
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:
Other - Last Name:WARNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:312 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:ID
Mailing Address - Zip Code:83644-5469
Mailing Address - Country:US
Mailing Address - Phone:208-761-8076
Mailing Address - Fax:
Practice Address - Street 1:312 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:ID
Practice Address - Zip Code:83644-5469
Practice Address - Country:US
Practice Address - Phone:208-761-8076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDA0010141Medicaid