Provider Demographics
NPI:1295113744
Name:DELAGRANGE, AMBER (SUDP)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:DELAGRANGE
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:
Other - Last Name:RENNELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1057 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2509
Mailing Address - Country:US
Mailing Address - Phone:360-636-3892
Mailing Address - Fax:
Practice Address - Street 1:2232 S SILVER LAKE RD
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:WA
Practice Address - Zip Code:98611-8021
Practice Address - Country:US
Practice Address - Phone:360-274-3262
Practice Address - Fax:360-274-3345
Is Sole Proprietor?:No
Enumeration Date:2015-05-15
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60476132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2084534Medicaid