Provider Demographics
NPI:1982906137
Name:AMBROSE, WADE FRECKER (COTA/L)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:FRECKER
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:WADE
Other - Middle Name:AMBROSE
Other - Last Name:FRECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:125 CITY POINT RD
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-7330
Mailing Address - Country:US
Mailing Address - Phone:207-338-9999
Mailing Address - Fax:
Practice Address - Street 1:125 CITY POINT RD
Practice Address - Street 2:
Practice Address - City:BELFAST
Practice Address - State:ME
Practice Address - Zip Code:04915-7330
Practice Address - Country:US
Practice Address - Phone:207-338-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-21
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOA2353224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant