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General NPI Number Information
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NPI Number | 1366250573
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Entity Type | Individual
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Provider Name | DERRICK BOGER
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Gender | Male
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Dates
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Enumeration Date | 12/19/2024
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Last Update Date | 12/19/2024
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Provider Practice Location Address
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Address Line | 2309 W CONE BLVD STE 220
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City | GREENSBORO
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State | NC
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Zip | 27408-4047
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Country | US
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Telephone | 336-491-5706
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Fax |
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Provider Business Mailing Address
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Address Line | 4720 CHESTERFIELD PL
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City | JAMESTOWN
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State | NC
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Zip | 27282-8656
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Country | US
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Telephone |
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Fax |
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | A20699
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License Number State | NC
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