Provider Demographics
NPI:1699167882
Name:AMBROSE, REBECCA (LMFT)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 ELM ST STE 204B
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:CT
Mailing Address - Zip Code:06468-2284
Mailing Address - Country:US
Mailing Address - Phone:203-521-5714
Mailing Address - Fax:
Practice Address - Street 1:324 ELM ST STE 204B
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-2284
Practice Address - Country:US
Practice Address - Phone:203-521-5714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001260106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT27-2529953OtherFEDERAL EIN