MEDICARE: DR. AMBRA ROBN ROSE BORN PSYD, LP

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	103TC0700X	Clinical Psychologist	PSY-3519	CO

General Provider Information

NPI Number	:	1720302920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMBRA ROBN ROSE BORN PSYD, LP

Provider Business Mailing Address
First Line	:	13659 E 104TH AVE
Second Line	:	SUITE 500B
City	:	COMMERCE CITY
State	:	CO
Zip	:	80022-9402
Country	:	US
Telephone Number	:	720-347-8836
Fax Number	:	855-244-3591

Provider Business Practice Location Address
First Line	:	13659 E 104TH AVE
Second Line	:	SUITE 500B
City	:	COMMERCE CITY
State	:	CO
Zip	:	80022-9402
Country	:	US
Telephone Number	:	720-347-8836
Fax Number	:	855-244-3591

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

Provider Enumeration Date	:	03/17/2010
Last Update Date	:	03/20/2013

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