=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750756482
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AUDRIA LYNETTE MUSGROVE MA, LPC, BC-TMH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2015
-----------------------------------------------------
Last Update Date | 04/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 MADISON SQ
-----------------------------------------------------
City | MINDEN
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71055-3095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-734-8553
-----------------------------------------------------
Fax | 844-769-7920
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 83
-----------------------------------------------------
City | DOYLINE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71023-0083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-734-8553
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 5204
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------