Provider Demographics
NPI:1952964355
Name:BAMBURG, CHEYNE LYNNE
Entity Type:Individual
Prefix:
First Name:CHEYNE
Middle Name:LYNNE
Last Name:BAMBURG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N COLLEGE RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-4263
Mailing Address - Country:US
Mailing Address - Phone:337-456-5705
Mailing Address - Fax:
Practice Address - Street 1:1602 W PINHOOK RD STE 303
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-3735
Practice Address - Country:US
Practice Address - Phone:337-806-9601
Practice Address - Fax:337-484-1405
Is Sole Proprietor?:No
Enumeration Date:2019-04-21
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-358103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst