Provider Demographics
NPI:1518218866
Name:REALE, AMBERROSE A (PSYD)
Entity type:Individual
Prefix:
First Name:AMBERROSE
Middle Name:A
Last Name:REALE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:AMBERROSE
Other - Middle Name:A
Other - Last Name:REALE-CALDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9235
Mailing Address - Fax:239-343-4008
Practice Address - Street 1:12600 CREEKSIDE LN STE 2
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3353
Practice Address - Country:US
Practice Address - Phone:239-343-9235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLPY11322103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116060800Medicaid