Provider Demographics
NPI:1679644629
Name:PRIDGEN, AMBER LEI (LSW)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:LEI
Last Name:PRIDGEN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1495 MORSE RD STE B3
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-6434
Mailing Address - Country:US
Mailing Address - Phone:614-267-7003
Mailing Address - Fax:614-267-7013
Practice Address - Street 1:3025 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-2653
Practice Address - Country:US
Practice Address - Phone:614-267-7003
Practice Address - Fax:614-279-7695
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS 0030705104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker