Basic Information
| Provider Information | |||||||||
| NPI: | 1154759223 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | LPCC, LCAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6301 19TH AVE NW | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587038899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018574232 | ||||||||
| FaxNumber: | 7018521190 | ||||||||
| Practice Location | |||||||||
| Address1: | 7151 15TH ST S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581046613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018574232 | ||||||||
| FaxNumber: | 7018521190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2013 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1695 | ND | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 787-6-1-14A | ND | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 75025 | 05 | ND | MEDICAID |