Healthcare Provider Details

I. General information

NPI: 1598261711
Provider Name (Legal Business Name): BONNIE L MUGRAGE LCDCII
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 02/13/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 MULBERRY HEIGHTS RD
POMEROY OH
45769-9573
US

IV. Provider business mailing address

224 COLUMBUS RD
ATHENS OH
45701-1334
US

V. Phone/Fax

Practice location:
  • Phone: 740-992-5277
  • Fax: 740-992-7264
Mailing address:
  • Phone: 740-592-6724
  • Fax: 740-592-6728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number011066
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: