Provider Demographics
NPI:1770012254
Name:MALL, AMBER (SAC-IT)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:MALL
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW GLARUS
Mailing Address - State:WI
Mailing Address - Zip Code:53574-9703
Mailing Address - Country:US
Mailing Address - Phone:608-219-5347
Mailing Address - Fax:
Practice Address - Street 1:151 E BADGER RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-2708
Practice Address - Country:US
Practice Address - Phone:608-250-2512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty