Provider Demographics
NPI:1417786591
Name:SLADE, AMBROSIA ANNETTANETTE II
Entity type:Individual
Prefix:
First Name:AMBROSIA
Middle Name:ANNETTANETTE
Last Name:SLADE
Suffix:II
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 1:8706 ANTONIO WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-1162
Mailing Address - Country:US
Mailing Address - Phone:209-284-3812
Mailing Address - Fax:
Practice Address - Street 1:8706 ANTONIO WAY
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-1162
Practice Address - Country:US
Practice Address - Phone:209-284-3812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician