Provider Demographics
NPI:1629384524
Name:AMBROSO, ALI (IMH8420)
Entity type:Individual
Prefix:MRS
First Name:ALI
Middle Name:
Last Name:AMBROSO
Suffix:
Gender:F
Credentials:IMH8420
Other - Prefix:
Other - First Name:ALYSON
Other - Middle Name:
Other - Last Name:AMBROSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 22308
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2308
Mailing Address - Country:US
Mailing Address - Phone:920-436-6800
Mailing Address - Fax:920-432-5966
Practice Address - Street 1:300 CROOKS ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4527
Practice Address - Country:US
Practice Address - Phone:920-436-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-30
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5043-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1629384524Medicaid