Provider Demographics
NPI:1639763147
Name:LIPONOGA, AMBER (LCSW)
Entity type:Individual
Prefix:MS
First Name:AMBER
Middle Name:
Last Name:LIPONOGA
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 CONLEY RD # 1032
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6465
Mailing Address - Country:US
Mailing Address - Phone:573-212-4456
Mailing Address - Fax:
Practice Address - Street 1:1500 FELLOWS PL APT 3C
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8529
Practice Address - Country:US
Practice Address - Phone:573-823-2842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-24
Last Update Date:2025-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190271911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490094703Medicaid