Basic Information
| Provider Information | |||||||||
| NPI: | 1629543145 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEDGE | ||||||||
| FirstName: | AMBER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 923 FINDLAY ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456624148 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 411 COURT ST | ||||||||
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| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456623932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403546685 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2018 | ||||||||
| LastUpdateDate: | 02/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA.169008 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | CDCA.172684 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | QMHS | OH | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | S.1800685 | OH | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | S.1800685-TRNE | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 0324182 | 05 | OH | MEDICAID | 0365182 | 05 | OH | MEDICAID |