Provider Demographics
NPI:1801123088
Name:SOUTHARD-ROBERSON, AMBER
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:SOUTHARD-ROBERSON
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:PO BOX 388
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:WY
Mailing Address - Zip Code:82836-0388
Mailing Address - Country:US
Mailing Address - Phone:307-655-9493
Mailing Address - Fax:
Practice Address - Street 1:66 COLUMBUS RD
Practice Address - Street 2:
Practice Address - City:PARKMAN
Practice Address - State:WY
Practice Address - Zip Code:82839-0388
Practice Address - Country:US
Practice Address - Phone:307-655-9493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-10
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator