Healthcare Provider Details

I. General information

NPI: 1699082479
Provider Name (Legal Business Name): BRANDON COY BOGLE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 N MAIN ST
RURAL RETREAT VA
24368-3123
US

IV. Provider business mailing address

7272 WURZBACH RD STE 601
SAN ANTONIO TX
78240-4803
US

V. Phone/Fax

Practice location:
  • Phone: 888-365-6271
  • Fax:
Mailing address:
  • Phone: 210-615-3483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810004813
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: