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General NPI Number Information
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NPI Number | 1518342393
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Entity Type | Organization
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Legal Business Name | MARK BOGERT
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Dates
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Enumeration Date | 07/22/2015
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Last Update Date | 11/08/2016
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Provider Practice Location Address
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Address Line | 5673 AIRPORT RD
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City | ROANOKE
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State | VA
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Zip | 24012-1119
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Country | US
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Telephone | 540-523-8080
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Fax | 540-562-8867
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Provider Business Mailing Address
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Address Line | 5673 AIRPORT RD
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City | ROANOKE
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State | VA
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Zip | 24012-1119
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Country | US
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Telephone | 540-523-8080
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Fax | 540-512-9775
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Authorized Official
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Title or Position | DIRECTOR
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Name | LISA M MCDOWELL
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Credential | LPC, LSATP, NCC
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Telephone | 540-523-8054
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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