Healthcare Provider Details

I. General information

NPI: 1457616609
Provider Name (Legal Business Name): AMBROSIA NOTTAGE LPC,CRC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2012
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29201 TELEGRAPH RD STE 550
SOUTHFIELD MI
48034-7664
US

IV. Provider business mailing address

22550 HALL RD
CLINTON TWP MI
48036-1189
US

V. Phone/Fax

Practice location:
  • Phone: 517-492-0784
  • Fax:
Mailing address:
  • Phone: 586-850-3011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401012758
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: