Provider Demographics
NPI:1760772693
Name:KOSTIAL, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:KOSTIAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE
Mailing Address - Street 2:DEPT 358
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9324
Mailing Address - Country:US
Mailing Address - Phone:360-788-6993
Mailing Address - Fax:360-788-6995
Practice Address - Street 1:2901 SQUALICUM PARKWAY
Practice Address - Street 2:BEHAVIORAL HEALTH SERVICES
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225
Practice Address - Country:US
Practice Address - Phone:360-788-6993
Practice Address - Fax:360-788-6995
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD605646522084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program