Provider Demographics
NPI:1578126496
Name:BAMBERG, MISTY DAWNE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:MISTY
Middle Name:DAWNE
Last Name:BAMBERG
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 RIBAUT RD
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5400
Mailing Address - Country:US
Mailing Address - Phone:843-524-8899
Mailing Address - Fax:
Practice Address - Street 1:507 FOREST CIR
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-2869
Practice Address - Country:US
Practice Address - Phone:843-549-1551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9578101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health