Healthcare Provider Details

I. General information

NPI: 1447906912
Provider Name (Legal Business Name): SUZANNE MARIE BOGDANOWICH LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUZANNE MARIE MURDOCK LMT

II. Dates (important events)

Enumeration Date: 02/23/2022
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1461 LAKELAND AVE UNIT 9
BOHEMIA NY
11716-2174
US

IV. Provider business mailing address

30 LEE AVE
PATCHOGUE NY
11772-3623
US

V. Phone/Fax

Practice location:
  • Phone: 631-467-8224
  • Fax:
Mailing address:
  • Phone: 631-672-1616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number024013-01
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: