Healthcare Provider Details

I. General information

NPI: 1710218516
Provider Name (Legal Business Name): AMBROSE BAROS LCSW, LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2010
Last Update Date: 07/15/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4210 MEADOWLARK LN SE
RIO RANCHO NM
87124-1021
US

IV. Provider business mailing address

3936 MOUNTAIN TRAIL LOOP NE
RIO RANCHO NM
87144-7001
US

V. Phone/Fax

Practice location:
  • Phone: 505-927-1024
  • Fax: 505-988-7328
Mailing address:
  • Phone: 505-927-1024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAD0189011
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-10327
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: