Healthcare Provider Details

I. General information

NPI: 1407989718
Provider Name (Legal Business Name): DAVID BRECK BOGGIO SW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 3338
ALBUQUERQUE NM
87190-3338
US

IV. Provider business mailing address

4717 HANNETT AVE NE
ALBUQUERQUE NM
87110-5015
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-5099
  • Fax:
Mailing address:
  • Phone: 505-514-8695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberZ 8589
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-4374
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: