Provider Demographics
NPI:1316735772
Name:BRADFORD, AMBUR LAVERNE
Entity type:Individual
Prefix:
First Name:AMBUR
Middle Name:LAVERNE
Last Name:BRADFORD
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 SAN FELIPE ST STE 990
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-1708
Mailing Address - Country:US
Mailing Address - Phone:470-491-2050
Mailing Address - Fax:
Practice Address - Street 1:115 N PARK TRL STE 123
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7373
Practice Address - Country:US
Practice Address - Phone:470-491-2050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA24-374919106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician