Provider Demographics
NPI:1780970715
Name:MADUME, AMBER RAE (BA, BS, BHRS, MS)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:RAE
Last Name:MADUME
Suffix:
Gender:F
Credentials:BA, BS, BHRS, MS
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:RAE
Other - Last Name:WOOTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA, BS, BHRS
Mailing Address - Street 1:202 LACEY LN
Mailing Address - Street 2:UNIT B
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-5551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6040 EARLE BROWN DR STE 100
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2561
Practice Address - Country:US
Practice Address - Phone:651-313-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225C00000X
MN4232101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor