Provider Demographics
NPI:1447884648
Name:RISTE, AMBER CHRISTINE
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:CHRISTINE
Last Name:RISTE
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 1:1924 DORCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48390-2990
Mailing Address - Country:US
Mailing Address - Phone:248-875-3086
Mailing Address - Fax:
Practice Address - Street 1:100 N STAEBLER RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-9755
Practice Address - Country:US
Practice Address - Phone:734-252-6522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI820799715106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty