Provider Demographics
NPI:1235122771
Name:AMBLE, BRENT LARRY (ATC, LAT)
Entity type:Individual
Prefix:MR
First Name:BRENT
Middle Name:LARRY
Last Name:AMBLE
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2116 CRAIG RD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6149
Mailing Address - Country:US
Mailing Address - Phone:715-858-4633
Mailing Address - Fax:715-858-4511
Practice Address - Street 1:2116 CRAIG RD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6149
Practice Address - Country:US
Practice Address - Phone:715-858-4633
Practice Address - Fax:715-858-4511
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer