Healthcare Provider Details

I. General information

NPI: 1841552296
Provider Name (Legal Business Name): TERESE MARIE AMBLE PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TERESE MARIE PERREAULT

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 02/05/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 SMITH AVE N
SAINT PAUL MN
55102-2346
US

IV. Provider business mailing address

345 SMITH AVE N
SAINT PAUL MN
55102-2346
US

V. Phone/Fax

Practice location:
  • Phone: 651-220-6720
  • Fax: 651-220-6707
Mailing address:
  • Phone: 651-220-6720
  • Fax: 651-220-6707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP5816
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: