Basic Information
| Provider Information | |||||||||
| NPI: | 1497907497 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUGERE | ||||||||
| FirstName: | SYDNA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 356 CHARLOTTE RD | ||||||||
| Address2: | |||||||||
| City: | RUTHERFORDTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281392916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282877945 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 356 CHARLOTTE RD | ||||||||
| Address2: | |||||||||
| City: | RUTHERFORDTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282877945 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 10779 | NC | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | 10779 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 10779 | 01 | NC | LICENSE | OTHER |