Provider Demographics
NPI:1568863470
Name:JO NELL R AMBURGEY, MSW, LICSW
Entity Type:Organization
Organization Name:JO NELL R AMBURGEY, MSW, LICSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JO NELL
Authorized Official - Middle Name:R
Authorized Official - Last Name:AMBURGEY
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:509-675-0642
Mailing Address - Street 1:PO BOX 513
Mailing Address - Street 2:
Mailing Address - City:KETTLE FALLS
Mailing Address - State:WA
Mailing Address - Zip Code:99141-0513
Mailing Address - Country:US
Mailing Address - Phone:509-675-0642
Mailing Address - Fax:
Practice Address - Street 1:298 S MAIN ST
Practice Address - Street 2:SUITE L3
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-2447
Practice Address - Country:US
Practice Address - Phone:509-675-0642
Practice Address - Fax:509-738-2561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW00007912251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAMBURJR513RUOtherDRIVERS LICENSE