Healthcare Provider Details

I. General information

NPI: 1952964355
Provider Name (Legal Business Name): CHEYNE LYNNE BAMBURG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2019
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 W PINHOOK RD STE 303
LAFAYETTE LA
70508-3735
US

IV. Provider business mailing address

401 N COLLEGE RD
LAFAYETTE LA
70506-4263
US

V. Phone/Fax

Practice location:
  • Phone: 337-806-9601
  • Fax: 337-484-1405
Mailing address:
  • Phone: 337-456-5705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberL-358
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: