Provider Demographics
NPI:1538724059
Name:AMBROSINI, ANITA L (QMHP)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:L
Last Name:AMBROSINI
Suffix:
Gender:F
Credentials:QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 W UMPQUA ST STE 1
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2979
Mailing Address - Country:US
Mailing Address - Phone:541-957-5646
Mailing Address - Fax:
Practice Address - Street 1:545 W UMPQUA ST STE 1
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2979
Practice Address - Country:US
Practice Address - Phone:541-957-5646
Practice Address - Fax:541-957-0191
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health