Provider Demographics
NPI:1215128608
Name:BAMBERY, MICHAEL ANDREW (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANDREW
Last Name:BAMBERY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44450 PINETREE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-3869
Mailing Address - Country:US
Mailing Address - Phone:734-738-0897
Mailing Address - Fax:
Practice Address - Street 1:44450 PINETREE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-3869
Practice Address - Country:US
Practice Address - Phone:734-738-0897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010839103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent