Provider Demographics
NPI:1679461180
Name:AMBAYE, ELIZABETH BRUK
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BRUK
Last Name:AMBAYE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 BLAISDELL AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2345
Mailing Address - Country:US
Mailing Address - Phone:206-883-1977
Mailing Address - Fax:651-344-0603
Practice Address - Street 1:2930 BLAISDELL AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2345
Practice Address - Country:US
Practice Address - Phone:206-883-1977
Practice Address - Fax:651-344-0603
Is Sole Proprietor?:No
Enumeration Date:2025-06-24
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNG527093671414106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician