Healthcare Provider Details

I. General information

NPI: 1306093414
Provider Name (Legal Business Name): LEVADA BAMBA CASAC-T
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2008
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 NIAGARA STREET ADOLESCENT PROGRAM
BUFFALO NY
14213
US

IV. Provider business mailing address

254 FRANKLIN STREET LAKE SHORE BEHAVIORAL HEALTH
BUFFALO NY
14202
US

V. Phone/Fax

Practice location:
  • Phone: 716-818-7195
  • Fax: 716-884-1758
Mailing address:
  • Phone: 716-842-0440
  • Fax: 716-842-4069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: