Individual
AMANDA DOMANGUE BOURG
Active
Individual
AMANDA DOMANGUE BOURG
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PHD
Taxonomy
Speciality
Code
Description
License number
State
103TC1900X
Counseling Psychologist
Primary
3783
TN
103TC1900X
Counseling Psychologist
915
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
3783
STATE PSYCHOLOGY LICENSURE
TN
01
—
915
STATE PSYCHOLOGY LICENSE
LA
Enumeration date
08/18/2006
Last updated
10/13/2022
Update your record
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