Provider Demographics
NPI:1386758068
Name:BOURG, AMANDA DOMANGUE (PHD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:DOMANGUE
Last Name:BOURG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 221
Mailing Address - Street 2:
Mailing Address - City:TELLICO PLAINS
Mailing Address - State:TN
Mailing Address - Zip Code:37385-0221
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:171 BANK ST # 221
Practice Address - Street 2:
Practice Address - City:TELLICO PLAINS
Practice Address - State:TN
Practice Address - Zip Code:37385-4987
Practice Address - Country:US
Practice Address - Phone:443-379-0447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3783103TC1900X
LA915103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA915OtherSTATE PSYCHOLOGY LICENSE
TN3783OtherSTATE PSYCHOLOGY LICENSURE