1750756482 NPI number — MISS AUDRIA LYNETTE MUSGROVE MA, LPC, BC-TMH

Table of content: MISS AUDRIA LYNETTE MUSGROVE MA, LPC, BC-TMH (NPI 1750756482)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750756482 NPI number — MISS AUDRIA LYNETTE MUSGROVE MA, LPC, BC-TMH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUSGROVE
Provider First Name:
AUDRIA
Provider Middle Name:
LYNETTE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
MA, LPC, BC-TMH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750756482
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 83
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOYLINE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71023-0083
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-734-8553
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 MADISON SQ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINDEN
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71055-3095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-734-8553
Provider Business Practice Location Address Fax Number:
844-769-7920
Provider Enumeration Date:
12/07/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 5204 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3618532 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 13859446 . This is a "CAQH" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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