Provider Demographics
NPI:1184376485
Name:HENRY, AMBER NICOLE (PEER SUPPORTER)
Entity type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:NICOLE
Last Name:HENRY
Suffix:
Gender:F
Credentials:PEER SUPPORTER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 S HAGUE AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-2405
Mailing Address - Country:US
Mailing Address - Phone:614-975-5849
Mailing Address - Fax:
Practice Address - Street 1:1195 SULLIVANT AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43223-1350
Practice Address - Country:US
Practice Address - Phone:614-975-5849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSS521668175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH102150043-00Medicaid