Provider Demographics
NPI:1639328867
Name:AMBORT, CASEY JO (MS)
Entity Type:Individual
Prefix:MRS
First Name:CASEY
Middle Name:JO
Last Name:AMBORT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MISS
Other - First Name:CASEY
Other - Middle Name:JO
Other - Last Name:PETERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:P.O. BOX 564
Mailing Address - Street 2:626 EAST SLIFER ST
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901
Mailing Address - Country:US
Mailing Address - Phone:608-742-8814
Mailing Address - Fax:608-742-2384
Practice Address - Street 1:626 EAST SLIFER ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901
Practice Address - Country:US
Practice Address - Phone:608-742-8814
Practice Address - Fax:608-742-2384
Is Sole Proprietor?:No
Enumeration Date:2008-09-11
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42579800Medicaid