Healthcare Provider Details

I. General information

NPI: 1689054736
Provider Name (Legal Business Name): TARA BUGG LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2015
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 HAZEN ST SUITE C
PAW PAW MI
49079
US

IV. Provider business mailing address

42590 56TH AVE
PAW PAW MI
49079-9732
US

V. Phone/Fax

Practice location:
  • Phone: 269-655-3367
  • Fax: 269-657-3474
Mailing address:
  • Phone: 269-303-0296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801098010
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: