Provider Demographics
NPI:1063053668
Name:MICHAEL, AMBER J (LSW)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:J
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4998 W BROAD ST STE 104
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228-1647
Mailing Address - Country:US
Mailing Address - Phone:614-754-8051
Mailing Address - Fax:614-319-6123
Practice Address - Street 1:4998 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-1647
Practice Address - Country:US
Practice Address - Phone:614-754-8051
Practice Address - Fax:614-319-6123
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-04
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.130161101YA0400X
OHS.2005695104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1063053668Medicaid
OHS.2005695OtherCOUNSELOR, SOCIAL WORKER, & MFT BOARD