Provider Demographics
NPI:1942895552
Name:AMBROSE, ALEXA RAE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:RAE
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02779-2318
Mailing Address - Country:US
Mailing Address - Phone:774-218-0669
Mailing Address - Fax:
Practice Address - Street 1:49 STATE RD
Practice Address - Street 2:WATUPPA BUILDING, SUITE 105
Practice Address - City:NORTH DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-0274
Practice Address - Country:US
Practice Address - Phone:508-985-1996
Practice Address - Fax:508-985-0067
Is Sole Proprietor?:No
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA77937-SP-SL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14406277OtherAMERICAN SPEECH LANGUAGE HEARING ASSOCIATIONS (ASHA)
MA77937-SP-SLOtherMA LICENSING