Provider Demographics
NPI:1356412522
Name:AMBURGEY, LAVENIA MICHELE (MA)
Entity type:Individual
Prefix:MS
First Name:LAVENIA
Middle Name:MICHELE
Last Name:AMBURGEY
Suffix:
Gender:F
Credentials:MA
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 2
Mailing Address - Street 2:
Mailing Address - City:REDFOX
Mailing Address - State:KY
Mailing Address - Zip Code:41847-0002
Mailing Address - Country:US
Mailing Address - Phone:606-633-0035
Mailing Address - Fax:
Practice Address - Street 1:84 E MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:WHITESBURG
Practice Address - State:KY
Practice Address - Zip Code:41858-7254
Practice Address - Country:US
Practice Address - Phone:606-633-0035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY148103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3017201Medicare ID - Type Unspecified