Provider Demographics
NPI:1295380863
Name:BOUGOR, SHYLA ROSE (LCPC)
Entity type:Individual
Prefix:
First Name:SHYLA
Middle Name:ROSE
Last Name:BOUGOR
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-5430
Mailing Address - Country:US
Mailing Address - Phone:618-928-0165
Mailing Address - Fax:
Practice Address - Street 1:10257 STATE ROUTE 3
Practice Address - Street 2:
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278-4418
Practice Address - Country:US
Practice Address - Phone:618-282-6233
Practice Address - Fax:888-388-1971
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-09
Last Update Date:2024-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180015824101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional