Provider Demographics
NPI:1588017461
Name:AMBERSOURCE, PLLC
Entity Type:Organization
Organization Name:AMBERSOURCE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA JANE
Authorized Official - Middle Name:C
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:989-529-3964
Mailing Address - Street 1:60 DIVISION ST STE B
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-2720
Mailing Address - Country:US
Mailing Address - Phone:989-529-3964
Mailing Address - Fax:231-723-5870
Practice Address - Street 1:60 DIVISION ST STE B
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-2720
Practice Address - Country:US
Practice Address - Phone:989-529-3964
Practice Address - Fax:231-723-5879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-15
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014966103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty