Provider Demographics
NPI:1437783222
Name:AMBROSE, HOLLY KELLY (LCSW)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:KELLY
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 BRISA LN
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7920
Mailing Address - Country:US
Mailing Address - Phone:331-210-4513
Mailing Address - Fax:
Practice Address - Street 1:11 BRISA LN
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7920
Practice Address - Country:US
Practice Address - Phone:331-210-4513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490086541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical