Provider Demographics
NPI:1508608654
Name:AMBER DISE PSYCHIATRY AND WELLNESS PLLC
Entity type:Organization
Organization Name:AMBER DISE PSYCHIATRY AND WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:NICOLE ANTOINNETTE
Authorized Official - Last Name:DISE
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, PMHNP-BC
Authorized Official - Phone:571-398-9278
Mailing Address - Street 1:12572 PLYMOUTH CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2321
Mailing Address - Country:US
Mailing Address - Phone:703-498-7684
Mailing Address - Fax:
Practice Address - Street 1:9524 WORKHOUSE RD RM 402
Practice Address - Street 2:
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079-2641
Practice Address - Country:US
Practice Address - Phone:571-398-9278
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health