Provider Demographics
NPI:1750889994
Name:MARTIN, AMBROCIA
Entity type:Individual
Prefix:
First Name:AMBROCIA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 CROYDEN RD
Mailing Address - Street 2:
Mailing Address - City:CHELTENHAM
Mailing Address - State:PA
Mailing Address - Zip Code:19012-1615
Mailing Address - Country:US
Mailing Address - Phone:267-226-5393
Mailing Address - Fax:
Practice Address - Street 1:2043 EASTBURN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19138-2636
Practice Address - Country:US
Practice Address - Phone:215-460-9005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC008909101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional