Provider Demographics
NPI:1013413111
Name:BRUINS, EMOGENE
Entity Type:Individual
Prefix:
First Name:EMOGENE
Middle Name:
Last Name:BRUINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4802 CONNELLA DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71302-2607
Mailing Address - Country:US
Mailing Address - Phone:318-445-2645
Mailing Address - Fax:
Practice Address - Street 1:1715 ASHLEY AVE STE A
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-7344
Practice Address - Country:US
Practice Address - Phone:318-625-7571
Practice Address - Fax:844-317-5579
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1902256886Medicaid