Provider Demographics
NPI:1568996759
Name:AMBROCIO, SEAN (OTR)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:AMBROCIO
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 W FREISTADT RD APT 6
Mailing Address - Street 2:
Mailing Address - City:THIENSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53092-1628
Mailing Address - Country:US
Mailing Address - Phone:210-268-6428
Mailing Address - Fax:
Practice Address - Street 1:9350 W FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53225-1714
Practice Address - Country:US
Practice Address - Phone:414-797-6028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-14
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6024-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist