Basic Information
| Provider Information | |||||||||
| NPI: | 1932521689 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AMBE | ||||||||
| FirstName: | NIBA | ||||||||
| MiddleName: | PROTUS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1571 VARNUM AVE | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018544901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9787618785 | ||||||||
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| Practice Location | |||||||||
| Address1: | 77 E MERRIMACK ST | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018521251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9784536800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2014 | ||||||||
| LastUpdateDate: | 01/15/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 801A22485 | 01 | MA | UNICARE | OTHER |