MEDICARE: MR. KEVIN RICHARD BOGSTAD MA LPC

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
2	103TC1900X	Counseling Psychologist	LPC.0014136	CO

General Provider Information

NPI Number	:	1124193180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEVIN RICHARD BOGSTAD MA LPC

Provider Business Mailing Address
First Line	:	1115 ELKTON DR STE 300
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-3597
Country	:	US
Telephone Number	:	951-837-3722
Fax Number	:

Provider Business Practice Location Address
First Line	:	1115 ELKTON DR STE 300
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-3597
Country	:	US
Telephone Number	:	951-837-3722
Fax Number	:

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

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	11/20/2017

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