Provider Demographics
NPI:1619642253
Name:GIDLEY BERG, AMBER ALEXIS (AUD)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:ALEXIS
Last Name:GIDLEY BERG
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 S 13TH ST FL 3
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4100
Mailing Address - Country:US
Mailing Address - Phone:360-848-8500
Mailing Address - Fax:360-419-7823
Practice Address - Street 1:307 S 13TH ST FL 3
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4100
Practice Address - Country:US
Practice Address - Phone:360-848-8500
Practice Address - Fax:360-419-7823
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAT006783231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty