Healthcare Provider Details

I. General information

NPI: 1164861233
Provider Name (Legal Business Name): DERRON K.G. AMBROSE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2013
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9048 ALTON ADAMS SR DR
ST. THOMAS VI
00802
US

IV. Provider business mailing address

PO BOX 600205
ST THOMAS VI
00801-6205
US

V. Phone/Fax

Practice location:
  • Phone: 340-776-8311
  • Fax:
Mailing address:
  • Phone: 340-776-8311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY60949800
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY60949800
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number22-047-PSY
License Number StateVI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: