Provider Demographics
NPI:1801468624
Name:TROTTA, AMBER L
Entity type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:L
Last Name:TROTTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 SW FOXTAIL DR
Mailing Address - Street 2:
Mailing Address - City:GRAIN VALLEY
Mailing Address - State:MO
Mailing Address - Zip Code:64029-9111
Mailing Address - Country:US
Mailing Address - Phone:816-305-6633
Mailing Address - Fax:
Practice Address - Street 1:912 SW FOXTAIL DR
Practice Address - Street 2:
Practice Address - City:GRAIN VALLEY
Practice Address - State:MO
Practice Address - Zip Code:64029-9111
Practice Address - Country:US
Practice Address - Phone:816-305-6633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1-21-51373103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO103K00000XMedicaid
MO1-21-51373Medicaid