Provider Demographics
NPI:1588189773
Name:GRAHAM, AMBER PATREESE (LCSW)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:PATREESE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:PATREESE
Other - Last Name:BIXLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:139 RIVER VISTA PL STE 106C
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3060
Mailing Address - Country:US
Mailing Address - Phone:208-731-0664
Mailing Address - Fax:
Practice Address - Street 1:139 RIVER VISTA PL STE 106C
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3060
Practice Address - Country:US
Practice Address - Phone:208-731-0664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-08
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-35827104100000X
IDLCSW-393831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker