Provider Demographics
NPI:1972325488
Name:AMBUSH, RENEE BERNADETTE (IMS, LM)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:BERNADETTE
Last Name:AMBUSH
Suffix:
Gender:F
Credentials:IMS, LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3156 MOUNT ZION RD APT 305
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4179
Mailing Address - Country:US
Mailing Address - Phone:443-722-9488
Mailing Address - Fax:
Practice Address - Street 1:3156 MOUNT ZION RD APT 305
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-4179
Practice Address - Country:US
Practice Address - Phone:443-722-9488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-26
Last Update Date:2024-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Single Specialty