Healthcare Provider Details

I. General information

NPI: 1235799925
Provider Name (Legal Business Name): THEODORE ROBERT BOGNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2019
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 EAST BLVD
CLEVELAND OH
44106-1702
US

IV. Provider business mailing address

12365 ALDERSYDE DR
CLEVELAND OH
44125-5554
US

V. Phone/Fax

Practice location:
  • Phone: 216-791-3800
  • Fax:
Mailing address:
  • Phone: 330-317-7154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1700599
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2102602
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: