Basic Information
| Provider Information | |||||||||
| NPI: | 1568105096 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DETAR | ||||||||
| FirstName: | AMBER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 937 N ROCKWELL AVE APT 64 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731275326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054080633 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4130 N LINCOLN BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731055209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054247711 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2022 | ||||||||
| LastUpdateDate: | 04/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.