Basic Information
| Provider Information | |||||||||
| NPI: | 1043653702 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMBROSE | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | SUZANNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3323 SHATTUCK RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486033184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894754171 | ||||||||
| FaxNumber: | 9893936021 | ||||||||
| Practice Location | |||||||||
| Address1: | 3323 SHATTUCK RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894754171 | ||||||||
| FaxNumber: | 9893936021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2013 | ||||||||
| LastUpdateDate: | 02/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401015523 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.