Provider Demographics
NPI:1821361619
Name:PAGE, AMBRIA JACQUELYN (LCSW)
Entity type:Individual
Prefix:
First Name:AMBRIA
Middle Name:JACQUELYN
Last Name:PAGE
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HARGROVE GRADE STE 1E
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-5116
Mailing Address - Country:US
Mailing Address - Phone:904-315-9248
Mailing Address - Fax:386-309-2350
Practice Address - Street 1:1 HARGROVE GRADE STE 1E
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-5116
Practice Address - Country:US
Practice Address - Phone:904-315-9248
Practice Address - Fax:386-309-2350
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW12139101YM0800X
FLSW 121391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health