Provider Demographics
NPI:1073659363
Name:DIERKS, AMBER ROSE (LMHP)
Entity type:Individual
Prefix:MISS
First Name:AMBER
Middle Name:ROSE
Last Name:DIERKS
Suffix:
Gender:F
Credentials:LMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 S 24TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68102-1226
Mailing Address - Country:US
Mailing Address - Phone:402-953-0977
Mailing Address - Fax:402-978-5637
Practice Address - Street 1:124 S 24TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102-1226
Practice Address - Country:US
Practice Address - Phone:860-661-7115
Practice Address - Fax:860-978-5637
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3437101YM0800X
IA000318106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist