Provider Demographics
NPI:1801289020
Name:BEHAVIORAL SPECIALISTS OF LA
Entity type:Organization
Organization Name:BEHAVIORAL SPECIALISTS OF LA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO/AGENT
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BAMBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-442-4498
Mailing Address - Street 1:925 OLIVE STREET
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104
Mailing Address - Country:US
Mailing Address - Phone:318-300-3560
Mailing Address - Fax:318-300-3561
Practice Address - Street 1:925 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2103
Practice Address - Country:US
Practice Address - Phone:318-300-3560
Practice Address - Fax:318-300-3561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-12
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA103K00000X, 103TC0700X
252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2384066Medicaid