Provider Demographics
NPI:1689333254
Name:AMBIS, ERICA (LW60977611)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:AMBIS
Suffix:
Gender:F
Credentials:LW60977611
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5718 S ALASKA ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-1309
Mailing Address - Country:US
Mailing Address - Phone:206-900-4640
Mailing Address - Fax:
Practice Address - Street 1:5718 S ALASKA ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-1309
Practice Address - Country:US
Practice Address - Phone:206-900-4640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW609776111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALW60977611OtherDOH