Provider Demographics
NPI:1689828907
Name:AMBROSE, MARLA K (SLP)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:K
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:MARLA
Other - Middle Name:
Other - Last Name:MAURICE-AMBROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:7052 S COLWOOD PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-7373
Mailing Address - Country:US
Mailing Address - Phone:208-412-9184
Mailing Address - Fax:
Practice Address - Street 1:1812 N MIDLAND BLVD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-1747
Practice Address - Country:US
Practice Address - Phone:208-442-2525
Practice Address - Fax:208-442-2505
Is Sole Proprietor?:No
Enumeration Date:2008-11-13
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTSLP-1771235Z00000X
IDSLP-1940235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist