Provider Demographics
NPI:1942558697
Name:BOUGOUNEAU, THERESA SHERYL (MED, LADC 1)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:SHERYL
Last Name:BOUGOUNEAU
Suffix:
Gender:F
Credentials:MED, LADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 JOHN ST # 2
Mailing Address - Street 2:
Mailing Address - City:ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02703-2027
Mailing Address - Country:US
Mailing Address - Phone:781-414-0099
Mailing Address - Fax:
Practice Address - Street 1:31 JOHN ST # 2
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-2027
Practice Address - Country:US
Practice Address - Phone:781-414-0099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
MA21620101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program