Provider Demographics
NPI:1649698721
Name:HENRY, AMBER (MED, CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10928 EAGLE RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-8078
Mailing Address - Country:US
Mailing Address - Phone:907-622-2122
Mailing Address - Fax:855-368-5399
Practice Address - Street 1:10928 EAGLE RIVER RD STE 104
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-8079
Practice Address - Country:US
Practice Address - Phone:907-622-2122
Practice Address - Fax:855-368-5399
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-04
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK74235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1675767Medicaid