Healthcare Provider Details

I. General information

NPI: 1720141567
Provider Name (Legal Business Name): TERESA AMBROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5170 US ROUTE 60
HUNTINGTON WV
25705-2004
US

IV. Provider business mailing address

6 MARTHA CT
BARBOURSVILLE WV
25504-9691
US

V. Phone/Fax

Practice location:
  • Phone: 304-399-2200
  • Fax: 304-399-2201
Mailing address:
  • Phone: 304-733-3358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number425
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: