Healthcare Provider Details

I. General information

NPI: 1225916562
Provider Name (Legal Business Name): NEISSA AMBROISE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2025
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 HYDE PARK AVE STE 202
HYDE PARK MA
02136-2819
US

IV. Provider business mailing address

891 CUMMINS HWY
MATTAPAN MA
02126-2039
US

V. Phone/Fax

Practice location:
  • Phone: 888-763-7272
  • Fax:
Mailing address:
  • Phone: 857-427-9432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: