Provider Demographics
NPI:1962013821
Name:IRVINE, AMBER (LPC, NCC)
Entity Type:Individual
Prefix:MS
First Name:AMBER
Middle Name:
Last Name:IRVINE
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3960 S PICASSO AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7893
Mailing Address - Country:US
Mailing Address - Phone:208-447-8043
Mailing Address - Fax:
Practice Address - Street 1:750 W USTICK RD STE 120
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-6133
Practice Address - Country:US
Practice Address - Phone:208-366-1601
Practice Address - Fax:208-366-1602
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-7355101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty