Provider Demographics
NPI:1710635669
Name:AMBROSINO, KRISTINE (BAS, MPA, MSW, RCSWI)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:AMBROSINO
Suffix:
Gender:F
Credentials:BAS, MPA, MSW, RCSWI
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:DANIELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4630 LIPSCOMB ST NE STE 1A
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-2940
Mailing Address - Country:US
Mailing Address - Phone:321-405-2583
Mailing Address - Fax:
Practice Address - Street 1:4630 LIPSCOMB ST NE STE 1A
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-2940
Practice Address - Country:US
Practice Address - Phone:321-405-2583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSWI168121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical