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General NPI Number Information
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NPI Number | 1104259027
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Entity Type | Individual
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Provider Name | WALTER ALBERT BOGUCKI CADC
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Gender | Male
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Dates
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Enumeration Date | 08/14/2013
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Last Update Date | 08/14/2013
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Provider Practice Location Address
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Address Line | 508 E FLORIDA AVE
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City | NAMPA
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State | ID
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Zip | 83686-5823
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Country | US
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Telephone | 208-463-0118
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Fax | 208-463-1507
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Provider Business Mailing Address
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Address Line | 508 E FLORIDA AVE
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City | NAMPA
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State | ID
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Zip | 83686-5823
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Country | US
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Telephone | 208-463-0118
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Fax | 208-463-1507
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 10067
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License Number State | ID
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