Provider Demographics
NPI:1538601042
Name:AMBROSE, MARY (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21160 MAPLE BRANCH TER
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-6160
Mailing Address - Country:US
Mailing Address - Phone:571-291-6192
Mailing Address - Fax:
Practice Address - Street 1:21160 MAPLE BRANCH TER
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-6160
Practice Address - Country:US
Practice Address - Phone:571-291-6192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01078899235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA495416Medicare UPIN
VA496734Medicare UPIN