Healthcare Provider Details

I. General information

NPI: 1184239964
Provider Name (Legal Business Name): MICHAEL BOGGESS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 12/29/2023
Certification Date: 12/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 PLEASANT VIEW WAY NW STE 300
ALBANY OR
97321-1789
US

IV. Provider business mailing address

PO BOX 1189
CORVALLIS OR
97339-1189
US

V. Phone/Fax

Practice location:
  • Phone: 541-812-3323
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3391
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: