Provider Demographics
NPI:1720347446
Name:AMBROSE, BRADEN (LPC)
Entity type:Individual
Prefix:
First Name:BRADEN
Middle Name:
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10475 PERRY HWY
Mailing Address - Street 2:TOWNE CENTRE SUITE 300
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-9274
Mailing Address - Country:US
Mailing Address - Phone:724-759-7500
Mailing Address - Fax:
Practice Address - Street 1:10475 PERRY HWY
Practice Address - Street 2:TOWNE CENTRE SUITE 300
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-9274
Practice Address - Country:US
Practice Address - Phone:724-759-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC004650101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor