Healthcare Provider Details

I. General information

NPI: 1871106575
Provider Name (Legal Business Name): ELISABETH MARY VOGT PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELISABETH MARY BRUZEK

II. Dates (important events)

Enumeration Date: 08/24/2020
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 UNIVERSITY AVE E
SAINT PAUL MN
55101-2507
US

IV. Provider business mailing address

9000 W WISCONSIN AVE
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 651-291-2848
  • Fax: 651-602-6885
Mailing address:
  • Phone: 414-955-0660
  • Fax: 414-955-0076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number3868
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number7090
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: