Provider Demographics
NPI:1396513933
Name:AMBROSE, AMANDA (LMSW-CC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:LMSW-CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6433
Mailing Address - Country:US
Mailing Address - Phone:207-922-4600
Mailing Address - Fax:
Practice Address - Street 1:67 ACME RD
Practice Address - Street 2:
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412-1524
Practice Address - Country:US
Practice Address - Phone:207-991-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC230861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical