Provider Demographics
NPI:1649754433
Name:AMBROSE, LAUREN M (ABA)
Entity Type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:M
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:ABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9649 W 55TH ST
Mailing Address - Street 2:
Mailing Address - City:COUNTRYSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-3699
Mailing Address - Country:US
Mailing Address - Phone:708-352-3580
Mailing Address - Fax:708-352-2715
Practice Address - Street 1:9649 W 55TH ST
Practice Address - Street 2:
Practice Address - City:COUNTRYSIDE
Practice Address - State:IL
Practice Address - Zip Code:60525-3699
Practice Address - Country:US
Practice Address - Phone:708-352-3580
Practice Address - Fax:708-352-2715
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid