Provider Demographics
NPI:1104648450
Name:VISINA, AMBER L (RBT)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:L
Last Name:VISINA
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3745 MERRIFIELD DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-2503
Mailing Address - Country:US
Mailing Address - Phone:701-441-4511
Mailing Address - Fax:
Practice Address - Street 1:4215 31ST AVE S STE A
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7743
Practice Address - Country:US
Practice Address - Phone:701-478-0221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-24-387646106S00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No174400000XOther Service ProvidersSpecialist