Provider Demographics
NPI:1720105802
Name:AMBROSE, STEPHEN ANTHONY (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ANTHONY
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 1:2927 ROLLING RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504-1638
Mailing Address - Country:US
Mailing Address - Phone:213-385-5100
Mailing Address - Fax:213-383-1820
Practice Address - Street 1:711 S NEW HAMPSHIRE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-1831
Practice Address - Country:US
Practice Address - Phone:213-385-5100
Practice Address - Fax:213-383-1820
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8968103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist