Provider Demographics
NPI:1194184903
Name:AMBROISE, MARIEANDREE
Entity type:Individual
Prefix:
First Name:MARIEANDREE
Middle Name:
Last Name:AMBROISE
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 1:998 CROOKED HILL RD
Mailing Address - Street 2:BUILDING 69
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-1019
Mailing Address - Country:US
Mailing Address - Phone:631-761-4205
Mailing Address - Fax:631-761-4184
Practice Address - Street 1:998 CROOKED HILL RD
Practice Address - Street 2:BUILDING 69
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-1019
Practice Address - Country:US
Practice Address - Phone:631-761-4205
Practice Address - Fax:631-761-4184
Is Sole Proprietor?:No
Enumeration Date:2016-02-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health