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NPI Code Detail

MEDICARE: LISA M AMBROSIUS AUD CCCASLP

MEDICARE: LISA M AMBROSIUS AUD CCCASLP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1235Z00000XSpeech-Language Pathologist1899154WI
2231H00000XAudiologist399156WI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1487632329
Entity Type Code : Individual
Provider Name (Legal Business Name) : LISA M AMBROSIUS AUD CCCASLP
Provider Business Mailing Address
First Line : 3200 SHORE DR
Second Line :
City : MARINETTE
State : WI
Zip : 54143-4292
Country : US
Telephone Number : 715-735-3187
Fax Number : 715-735-5848
Provider Business Practice Location Address
First Line : 1715 DOUSMAN ST
Second Line :
City : GREEN BAY
State : WI
Zip : 54303-3211
Country : US
Telephone Number : 920-405-1414
Fax Number : 920-405-1462
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/31/2005
Last Update Date : 06/19/2020

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