Provider Demographics
NPI:1164861233
Name:AMBROSE, DERRON KG (PHD)
Entity Type:Individual
Prefix:DR
First Name:DERRON
Middle Name:KG
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 5
Mailing Address - Street 2:
Mailing Address - City:ST THOMAS
Mailing Address - State:VI
Mailing Address - Zip Code:00804-0005
Mailing Address - Country:US
Mailing Address - Phone:340-714-2348
Mailing Address - Fax:
Practice Address - Street 1:6115 ESTATE SMITH BAY UNIT 5
Practice Address - Street 2:
Practice Address - City:ST THOMAS
Practice Address - State:VI
Practice Address - Zip Code:00802-1330
Practice Address - Country:US
Practice Address - Phone:340-714-2348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60949800103TC0700X, 103T00000X
VI22-047-PSY103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical