Healthcare Provider Details

I. General information

NPI: 1669984142
Provider Name (Legal Business Name): PETER BOGART LPC, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2017
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7710 CARONDELET SUITE #204
SAINT LOUIS MO
63105
US

IV. Provider business mailing address

343 S KIRKWOOD RD UNIT 221231
SAINT LOUIS MO
63122-7064
US

V. Phone/Fax

Practice location:
  • Phone: 314-403-2611
  • Fax:
Mailing address:
  • Phone: 314-403-2611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2011036949
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: