Provider Demographics
NPI:1053939850
Name:BOGGS, MELISSA SHAVON (LPC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:SHAVON
Last Name:BOGGS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 VISTA VALET APT 202
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-1737
Mailing Address - Country:US
Mailing Address - Phone:254-368-4442
Mailing Address - Fax:
Practice Address - Street 1:8401 DATAPOINT DR STE 900
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5385
Practice Address - Country:US
Practice Address - Phone:210-664-0654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80186101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty