Healthcare Provider Details

I. General information

NPI: 1487632329
Provider Name (Legal Business Name): LISA M AMBROSIUS AUD CCCASLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA MARTIN

II. Dates (important events)

Enumeration Date: 12/31/2005
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 DOUSMAN ST
GREEN BAY WI
54303-3211
US

IV. Provider business mailing address

3200 SHORE DR
MARINETTE WI
54143-4292
US

V. Phone/Fax

Practice location:
  • Phone: 920-405-1414
  • Fax: 920-405-1462
Mailing address:
  • Phone: 715-735-3187
  • Fax: 715-735-5848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1899154
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number399156
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: