Healthcare Provider Details

I. General information

NPI: 1992440036
Provider Name (Legal Business Name): MARYBETH AMPLO MA, LPC, ATR-BC.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2022
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MANHATTANVILLE RD STE 203
PURCHASE NY
10577-2118
US

IV. Provider business mailing address

PO BOX 48392
CUMBERLAND NC
28331-8392
US

V. Phone/Fax

Practice location:
  • Phone: 800-835-2362
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC014318
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: