Provider Demographics
NPI:1295171965
Name:AMBROSE, LEROY (MS)
Entity type:Individual
Prefix:
First Name:LEROY
Middle Name:
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 HARDING AVE
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:PA
Mailing Address - Zip Code:19070-1503
Mailing Address - Country:US
Mailing Address - Phone:610-547-3904
Mailing Address - Fax:
Practice Address - Street 1:2514 N. BROAD ST.
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19132
Practice Address - Country:US
Practice Address - Phone:610-547-3904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health