MEDICARE: PETER BOGHDADI MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	11312	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083969521
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER BOGHDADI MS

Provider Business Mailing Address
First Line	:	350 SHAW AVE
Second Line	:
City	:	SOUTHERN PINES
State	:	NC
Zip	:	28387-6237
Country	:	US
Telephone Number	:	910-580-8280
Fax Number	:	910-304-5633

Provider Business Practice Location Address
First Line	:	350 SHAW AVE
Second Line	:
City	:	SOUTHERN PINES
State	:	NC
Zip	:	28387-6237
Country	:	US
Telephone Number	:	910-580-8280
Fax Number	:	910-304-5633

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2012
Last Update Date	:	01/18/2023

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