Provider Demographics
NPI:1891123865
Name:D'AMBROSIO, JUSTIN (BCBA, NYS-LBA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:D'AMBROSIO
Suffix:
Gender:M
Credentials:BCBA, NYS-LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 WAYNE CT
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-9108
Mailing Address - Country:US
Mailing Address - Phone:518-744-4834
Mailing Address - Fax:
Practice Address - Street 1:17 WAYNE CT
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-9108
Practice Address - Country:US
Practice Address - Phone:518-744-4834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-29
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000-719-1103K00000X
1-14-9594103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst