Provider Demographics
NPI:1952860231
Name:AMBROSE, JOSEPH (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 FRENCH ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-2929
Mailing Address - Country:US
Mailing Address - Phone:860-945-5077
Mailing Address - Fax:
Practice Address - Street 1:324 FRENCH ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-2929
Practice Address - Country:US
Practice Address - Phone:860-417-7194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6795487707103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT6795487707Medicaid