Healthcare Provider Details

I. General information

NPI: 1164512349
Provider Name (Legal Business Name): SUSAN MARIE AMBROSIUS X LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10015 OVERSEAS HWY
MARATHON FL
33050-3336
US

IV. Provider business mailing address

136 MOCKINGBIRD LN
MARATHON FL
33050-2415
US

V. Phone/Fax

Practice location:
  • Phone: 305-289-2779
  • Fax:
Mailing address:
  • Phone: 305-395-1779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH7434
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: