Healthcare Provider Details

I. General information

NPI: 1104741040
Provider Name (Legal Business Name): DEJAH NILES-BOGGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

249 CENTRAL PARK AVE STE 300
VIRGINIA BEACH VA
23462-3271
US

IV. Provider business mailing address

249 CENTRAL PARK AVE STE 300
VIRGINIA BEACH VA
23462-3271
US

V. Phone/Fax

Practice location:
  • Phone: 757-524-1318
  • Fax:
Mailing address:
  • Phone: 757-524-1318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0704019415
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: