Provider Demographics
NPI:1487924064
Name:PEGUES, ANGELA DENISE
Entity type:Individual
Prefix:MISS
First Name:ANGELA
Middle Name:DENISE
Last Name:PEGUES
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:ANGELA
Other - Middle Name:DENISE
Other - Last Name:PEGUES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LSCW
Mailing Address - Street 1:320 S FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-4539
Mailing Address - Country:US
Mailing Address - Phone:318-283-0868
Mailing Address - Fax:
Practice Address - Street 1:320 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-4539
Practice Address - Country:US
Practice Address - Phone:318-283-0868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA66131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA6613Medicaid