Healthcare Provider Details

I. General information

NPI: 1023235678
Provider Name (Legal Business Name): CHUCK C. BUGLE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 W. SPRING ST.
ANNA IL
62906
US

IV. Provider business mailing address

311 W. SPRING ST.
ANNA IL
62906
US

V. Phone/Fax

Practice location:
  • Phone: 618-353-7180
  • Fax:
Mailing address:
  • Phone: 618-353-7180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: