Provider Demographics
NPI:1891004206
Name:CHAN, AMBER MARIE (LPC-MH)
Entity Type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:MARIE
Last Name:CHAN
Suffix:
Gender:F
Credentials:LPC-MH
Other - Prefix:MISS
Other - First Name:AMBER
Other - Middle Name:MARIE
Other - Last Name:WIDENOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5708 S REMINGTON PL STE 400
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-5160
Mailing Address - Country:US
Mailing Address - Phone:605-321-9906
Mailing Address - Fax:
Practice Address - Street 1:5708 S REMINGTON PL STE 400
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108
Practice Address - Country:US
Practice Address - Phone:605-321-9906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-03
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004204-1101YM0800X
SDLPC-MH2201101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health