Provider Demographics
NPI:1003913435
Name:AMBROSE, TIMOTHY KEMP (PHD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:KEMP
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1476
Mailing Address - Street 2:
Mailing Address - City:PAHOA
Mailing Address - State:HI
Mailing Address - Zip Code:96778-1476
Mailing Address - Country:US
Mailing Address - Phone:808-965-9416
Mailing Address - Fax:808-965-1661
Practice Address - Street 1:14-4034 PAHOA-KALAPANA ROAD
Practice Address - Street 2:
Practice Address - City:PAHOA
Practice Address - State:HI
Practice Address - Zip Code:96778
Practice Address - Country:US
Practice Address - Phone:808-965-9416
Practice Address - Fax:808-965-1661
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY-735103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI53129501OtherALOHACARE PIN NUMBER
HI53129501Medicaid
HIPSY-735OtherQUEENS MDX PIN NUMBER
HI0000240218OtherQUEST PIN NUMBER
HI0240218OtherHMSA PIN NUMBER
HI0000240218OtherQUEST PIN NUMBER