MEDICARE: MS. VICKIE ANN BOGAN R.B.T.

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	222Q00000X	Developmental Therapist
2	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1427496926
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VICKIE ANN BOGAN R.B.T.

Provider Business Mailing Address
First Line	:	169 APPLEWOOD DR APT 5
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39702-9002
Country	:	US
Telephone Number	:	662-497-6712
Fax Number	:

Provider Business Practice Location Address
First Line	:	1101 W 40TH ST STE 102
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78756-3609
Country	:	US
Telephone Number	:	855-223-7123
Fax Number	:

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

Provider Enumeration Date	:	06/06/2013
Last Update Date	:	11/21/2022

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