MEDICARE: ERICA AMBIS LW60977611

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
1	1041C0700X	Clinical Social Worker	LW60977611	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LW60977611	OTHER	WA	DOH

General Provider Information

NPI Number	:	1689333254
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERICA AMBIS LW60977611

Provider Business Mailing Address
First Line	:	8350 VERDE CIR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79907-4233
Country	:	US
Telephone Number	:	206-900-4640
Fax Number	:

Provider Business Practice Location Address
First Line	:	8350 VERDE CIR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79907-4233
Country	:	US
Telephone Number	:	206-900-4640
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/10/2021
Last Update Date	:	05/07/2024

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