Healthcare Provider Details

I. General information

NPI: 1073107702
Provider Name (Legal Business Name): MAIRA LARA AMBRIS SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2021
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 14TH AVE W
POLSON MT
59860-5321
US

IV. Provider business mailing address

9 14TH AVE W
POLSON MT
59860-5321
US

V. Phone/Fax

Practice location:
  • Phone: 406-883-4378
  • Fax:
Mailing address:
  • Phone: 406-883-4378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberPRD-SP-LIC-12708
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: