Provider Demographics
NPI:1669670915
Name:AMBROSINO, JODIE MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JODIE
Middle Name:MARIE
Last Name:AMBROSINO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CHURCH ST S
Mailing Address - Street 2:SUITE 404
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1717
Mailing Address - Country:US
Mailing Address - Phone:203-785-5282
Mailing Address - Fax:203-764-6748
Practice Address - Street 1:2 CHURCH ST S
Practice Address - Street 2:SUITE 404
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1717
Practice Address - Country:US
Practice Address - Phone:203-785-5282
Practice Address - Fax:203-764-6748
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002646103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent