MEDICARE: DR. VIRGINIA BOGA PH.D.

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	103TC0700X	Clinical Psychologist	020129	NY

General Provider Information

NPI Number	:	1649511783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VIRGINIA BOGA PH.D.

Provider Business Mailing Address
First Line	:	979 LAMONT AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10309-2207
Country	:	US
Telephone Number	:	347-524-4169
Fax Number	:

Provider Business Practice Location Address
First Line	:	979 LAMONT AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10309-2207
Country	:	US
Telephone Number	:	347-524-4169
Fax Number	:

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

Provider Enumeration Date	:	03/14/2013
Last Update Date	:	06/25/2013

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