=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871736264
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUANTA T BUGGAGE M.ED.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2009
-----------------------------------------------------
Last Update Date | 04/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5941 DENNIS MACK LN
-----------------------------------------------------
City | ETHEL
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70730-4031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-244-1823
-----------------------------------------------------
Fax | 225-683-4882
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5941 DENNIS MACK LN
-----------------------------------------------------
City | ETHEL
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70730-4031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-244-1823
-----------------------------------------------------
Fax | 225-683-4882
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 5824
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------