Provider Demographics
NPI:1750750493
Name:WELLBORN, AMBER (LMT)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:WELLBORN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 HIDDEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MT
Mailing Address - Zip Code:59833-6955
Mailing Address - Country:US
Mailing Address - Phone:406-396-0387
Mailing Address - Fax:
Practice Address - Street 1:336 HIDDEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MT
Practice Address - Zip Code:59833-6955
Practice Address - Country:US
Practice Address - Phone:406-396-0387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC-2625225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist