Provider Demographics
NPI:1821422502
Name:BOGUE, LINDA ANN
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:ANN
Last Name:BOGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LINDA
Other - Middle Name:ANN
Other - Last Name:PEARCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRAADC/CCDP
Mailing Address - Street 1:12114 DAVID LN
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-8308
Mailing Address - Country:US
Mailing Address - Phone:417-781-7768
Mailing Address - Fax:
Practice Address - Street 1:2919 E 4TH ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-1625
Practice Address - Country:US
Practice Address - Phone:417-782-7966
Practice Address - Fax:417-624-4558
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1215101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)