Provider Demographics
NPI:1306160924
Name:FOX, AMBERLYNN
Entity type:Individual
Prefix:
First Name:AMBERLYNN
Middle Name:
Last Name:FOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1908 BUSINESS CENTER DR STE 220
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3468
Mailing Address - Country:US
Mailing Address - Phone:909-890-5930
Mailing Address - Fax:
Practice Address - Street 1:790 VIA LATA STE 300
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3978
Practice Address - Country:US
Practice Address - Phone:909-433-0445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-25
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health