Healthcare Provider Details

I. General information

NPI: 1205876570
Provider Name (Legal Business Name): MELISSA BOGGS MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8926 CHESAPEAKE AVE
NORTH BEACH MD
20714
US

IV. Provider business mailing address

12941 BARREDA BLVD
LUSBY MD
20657-4101
US

V. Phone/Fax

Practice location:
  • Phone: 410-286-3341
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number21026
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: