Provider Demographics
NPI:1598427585
Name:AMBROSE, MERIDITH LARA (PHD)
Entity Type:Individual
Prefix:DR
First Name:MERIDITH
Middle Name:LARA
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MEREDITH
Other - Middle Name:
Other - Last Name:AMBROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28 W 3RD ST APT 1430
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-1787
Mailing Address - Country:US
Mailing Address - Phone:973-600-8866
Mailing Address - Fax:
Practice Address - Street 1:295 CENTRAL PARK W OFC 6
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-3021
Practice Address - Country:US
Practice Address - Phone:973-600-8866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023769103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist