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General NPI Number Information
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NPI Number | 1861920415
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Entity Type | Individual
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Provider Name | TAMARA BOGLE LCSW
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Gender | Female
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Dates
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Enumeration Date | 05/26/2017
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Last Update Date | 05/26/2017
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Provider Practice Location Address
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Address Line | 1849 E 1ST AVE
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City | CRESTVIEW
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State | FL
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Zip | 32539-3109
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Country | US
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Telephone | 850-333-9297
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Fax |
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Provider Business Mailing Address
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Address Line | 1641 BEL AIRE DR
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City | CRESTVIEW
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State | FL
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Zip | 32536-3242
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | SW12202
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License Number State | FL
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