Provider Demographics
NPI:1487632329
Name:AMBROSIUS, LISA M (AUD CCCASLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:AMBROSIUS
Suffix:
Gender:F
Credentials:AUD CCCASLP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3200 SHORE DR
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-4292
Mailing Address - Country:US
Mailing Address - Phone:715-735-3187
Mailing Address - Fax:715-735-5848
Practice Address - Street 1:1715 DOUSMAN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3211
Practice Address - Country:US
Practice Address - Phone:920-405-1414
Practice Address - Fax:920-405-1462
Is Sole Proprietor?:No
Enumeration Date:2005-12-31
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1899154235Z00000X
WI399156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42782500Medicaid
WI41147800Medicaid