Provider Demographics
NPI:1063814804
Name:BUGG, EBONI (LCSW)
Entity Type:Individual
Prefix:
First Name:EBONI
Middle Name:
Last Name:BUGG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 4TH ST NW STE W
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-4593
Mailing Address - Country:US
Mailing Address - Phone:434-202-7692
Mailing Address - Fax:434-202-7694
Practice Address - Street 1:233 4TH ST NW STE W
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-4593
Practice Address - Country:US
Practice Address - Phone:434-202-7692
Practice Address - Fax:434-202-7694
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040080871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical