MEDICARE: DR. NAOMI AMBALU, LLC

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	261QM0850X	Adult Mental Health Clinic/Center
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1780192401
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. NAOMI AMBALU, LLC

Provider Business Mailing Address
First Line	:	115 FRANKLIN TPKE STE 139
Second Line	:
City	:	MAHWAH
State	:	NJ
Zip	:	07430-1325
Country	:	US
Telephone Number	:	908-998-2288
Fax Number	:

Provider Business Practice Location Address
First Line	:	115 FRANKLIN TPKE STE 139
Second Line	:
City	:	MAHWAH
State	:	NJ
Zip	:	07430-1325
Country	:	US
Telephone Number	:	908-998-2288
Fax Number	:	705-995-2043

Authorized Official
Title or Position	:	OWNER
Name	:	DR. NAOMI AMBALU
Credential	:	DO
Telephone Number	:	908-998-2288

Provider Enumeration Date	:	01/16/2018
Last Update Date	:	09/25/2018

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