Provider Demographics
NPI:1295417087
Name:AKPOROGUAFE, BRENDA DIANE (LMT)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:DIANE
Last Name:AKPOROGUAFE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2432B RIVER OAKS BLVD APT B
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-3602
Mailing Address - Country:US
Mailing Address - Phone:601-307-9676
Mailing Address - Fax:
Practice Address - Street 1:210 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-2312
Practice Address - Country:US
Practice Address - Phone:337-600-8623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1346954211103TC0700X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1346954211OtherNPI