Provider Demographics
NPI:1609225275
Name:AMBROGIO, GINA MARIE (LLMSW, BCABA)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:AMBROGIO
Suffix:
Gender:F
Credentials:LLMSW, BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 W ALEXANDRINE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2015
Mailing Address - Country:US
Mailing Address - Phone:313-831-5535
Mailing Address - Fax:313-831-2608
Practice Address - Street 1:79 W ALEXANDRINE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2015
Practice Address - Country:US
Practice Address - Phone:313-831-5535
Practice Address - Fax:313-831-2608
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0-16-7335106E00000X
MI68010991181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical