Provider Demographics
NPI: | 1942308028 |
---|---|
Name: | BUGBEE, DOUGLAS C (LICSW) |
Entity Type: | Individual |
Prefix: | |
First Name: | DOUGLAS |
Middle Name: | C |
Last Name: | BUGBEE |
Suffix: | |
Gender: | M |
Credentials: | LICSW |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 89 FLORAL ST |
Mailing Address - Street 2: | |
Mailing Address - City: | SOUTH BURLINGTON |
Mailing Address - State: | VT |
Mailing Address - Zip Code: | 05403-3000 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 802-660-8393 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 617 RIVERSIDE AVE |
Practice Address - Street 2: | |
Practice Address - City: | BURLINGTON |
Practice Address - State: | VT |
Practice Address - Zip Code: | 05401-1601 |
Practice Address - Country: | US |
Practice Address - Phone: | 802-864-6309 |
Practice Address - Fax: | 802-860-4324 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-09-20 |
Last Update Date: | 2007-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
VT | 0890000407 | 1041C0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
374165 | Other | MVP | |
28119 | Other | BLUE CROSS BLUE SHIELD | |
2041724 | Other | CIGNA BEHAVIORAL HEALTH | |
079597 | Other | VALUE OPTIONS | |
VT | 1007510 | Medicaid | |
VT | VN2881 | Medicare ID - Type Unspecified |