Healthcare Provider Details

I. General information

NPI: 1770202236
Provider Name (Legal Business Name): LICENSED BEHAVIOR ANALYST L BOGDAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2022
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 STONEGATE DR
STATEN ISLAND NY
10304-4432
US

IV. Provider business mailing address

41 STONEGATE DR
STATEN ISLAND NY
10304-4432
US

V. Phone/Fax

Practice location:
  • Phone: 347-414-6195
  • Fax:
Mailing address:
  • Phone: 347-414-6195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LILIYA BOGDAN
Title or Position: PRESIDENT
Credential: BCBA LBA MS.ED
Phone: 347-414-6195