Provider Demographics
NPI:1679243208
Name:BAMBERG, ROBERT TRENT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:TRENT
Last Name:BAMBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 BELCHER ST
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35042-2946
Mailing Address - Country:US
Mailing Address - Phone:205-926-2992
Mailing Address - Fax:205-316-7675
Practice Address - Street 1:160 4TH ST
Practice Address - Street 2:
Practice Address - City:BRENT
Practice Address - State:AL
Practice Address - Zip Code:35034-3739
Practice Address - Country:US
Practice Address - Phone:205-928-6045
Practice Address - Fax:205-316-7675
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC3820A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor