MEDICARE: MRS. EILEEN AMBROSELLI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1588915680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. EILEEN AMBROSELLI

Provider Business Mailing Address
First Line	:	191 CLINTON ST
Second Line	:
City	:	AVON
State	:	NY
Zip	:	14414-1413
Country	:	US
Telephone Number	:	585-226-2455
Fax Number	:

Provider Business Practice Location Address
First Line	:	191 CLINTON ST
Second Line	:
City	:	AVON
State	:	NY
Zip	:	14414-1413
Country	:	US
Telephone Number	:	585-226-2455
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2012
Last Update Date	:	09/28/2012

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Directions to “ MRS. EILEEN AMBROSELLI ” Practice Location

Language	Start Address	Practice Location

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