Provider Demographics
NPI:1336775600
Name:BUGNA, PHYLICIA JEAN
Entity type:Individual
Prefix:
First Name:PHYLICIA
Middle Name:JEAN
Last Name:BUGNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3190 TYRONE BLVD N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-2919
Mailing Address - Country:US
Mailing Address - Phone:727-345-9111
Mailing Address - Fax:
Practice Address - Street 1:3190 TYRONE BLVD N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-2919
Practice Address - Country:US
Practice Address - Phone:727-345-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-114086106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician