Provider Demographics
NPI:1295943082
Name:BUMBERRY, LAURA A (PSYD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:BUMBERRY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:LAURA
Other - Middle Name:BUMBERRY
Other - Last Name:SCHUMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1129 MACKLIND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1440
Mailing Address - Country:US
Mailing Address - Phone:314-534-0200
Mailing Address - Fax:314-534-7996
Practice Address - Street 1:1129 MACKLIND AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1440
Practice Address - Country:US
Practice Address - Phone:314-534-0200
Practice Address - Fax:314-534-7996
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009034694103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO23-2812942OtherST. LOUIS BEHAVIORAL MEDICINE INSTITUTE