MEDICARE: BRANDY BOGU P-960

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	P-960	NE

General Provider Information

NPI Number	:	1396040556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDY BOGU P-960

Provider Business Mailing Address
First Line	:	425 N OAK ST
Second Line	:
City	:	NORTH PLATTE
State	:	NE
Zip	:	69101-3764
Country	:	US
Telephone Number	:	308-532-8300
Fax Number	:

Provider Business Practice Location Address
First Line	:	425 N OAK ST
Second Line	:
City	:	NORTH PLATTE
State	:	NE
Zip	:	69101-3764
Country	:	US
Telephone Number	:	308-532-8300
Fax Number	:

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

Provider Enumeration Date	:	01/20/2011
Last Update Date	:	01/20/2011

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