Provider Demographics
NPI:1225208226
Name:SCRUGGS, PROVILLA HENDERSON (MED)
Entity Type:Individual
Prefix:MS
First Name:PROVILLA
Middle Name:HENDERSON
Last Name:SCRUGGS
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13010 FLAXSEED WAY
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-3408
Mailing Address - Country:US
Mailing Address - Phone:281-564-4348
Mailing Address - Fax:281-564-4786
Practice Address - Street 1:8303 SOUTHWEST FWY
Practice Address - Street 2:640
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-1600
Practice Address - Country:US
Practice Address - Phone:832-816-8984
Practice Address - Fax:832-816-8984
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX723101YA0400X
TX1929106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX070928901Medicaid