=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881079200
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALICIA BOGARD LISW-S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2015
-----------------------------------------------------
Last Update Date | 07/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 60 HARRIS AVE
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44857-2458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-706-6301
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 60 HARRIS AVE
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44857-2458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I.1101607-SUPV
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------