Provider Demographics
NPI:1851696512
Name:AMBRUTIS, SHANNON I (MHRT-1)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:I
Last Name:AMBRUTIS
Suffix:
Gender:F
Credentials:MHRT-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 AIRPORT DR
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769-2041
Mailing Address - Country:US
Mailing Address - Phone:207-764-0759
Mailing Address - Fax:207-764-5631
Practice Address - Street 1:2 AIRPORT DR
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-2041
Practice Address - Country:US
Practice Address - Phone:207-764-0759
Practice Address - Fax:207-764-5631
Is Sole Proprietor?:No
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME103850000Medicaid