Provider Demographics
NPI:1467565507
Name:AMBURGEY, LEE J (PA)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:J
Last Name:AMBURGEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-0790
Mailing Address - Country:US
Mailing Address - Phone:606-329-8588
Mailing Address - Fax:606-329-8195
Practice Address - Street 1:3701 LANSDOWNE DRIVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41102
Practice Address - Country:US
Practice Address - Phone:606-324-3005
Practice Address - Fax:660-632-9153
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0036103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30610026Medicaid
000000359706OtherANTHEM BCBS