Provider Demographics
NPI:1548634876
Name:AMBRICO, STEVEN (LCSW)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:AMBRICO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WAHOO DR
Mailing Address - Street 2:SARP
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349
Mailing Address - Country:US
Mailing Address - Phone:860-694-4021
Mailing Address - Fax:310-373-4257
Practice Address - Street 1:1 WAHOO DR
Practice Address - Street 2:SARP
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349
Practice Address - Country:US
Practice Address - Phone:860-694-4021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-24
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CA827411041C0700X
CT0101561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004040564Medicaid