Provider Demographics
NPI:1790133585
Name:VINSON-BOGAN, TEQUILA (MA, LPCA)
Entity Type:Individual
Prefix:
First Name:TEQUILA
Middle Name:
Last Name:VINSON-BOGAN
Suffix:
Gender:F
Credentials:MA, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 YONKERS RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-2258
Mailing Address - Country:US
Mailing Address - Phone:919-896-7536
Mailing Address - Fax:919-838-8454
Practice Address - Street 1:2000 YONKERS RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-2258
Practice Address - Country:US
Practice Address - Phone:919-896-7536
Practice Address - Fax:919-838-8454
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA12343101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional