Provider Demographics
NPI:1023357134
Name:BOGDANOFF, MICHAEL GORDON (SLP MA JD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GORDON
Last Name:BOGDANOFF
Suffix:
Gender:M
Credentials:SLP MA JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 SULLLIVAN TRAIL
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18040-7958
Mailing Address - Country:US
Mailing Address - Phone:800-944-9782
Mailing Address - Fax:610-438-2046
Practice Address - Street 1:6000 SANTA ROSA RD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-7101
Practice Address - Country:US
Practice Address - Phone:805-388-8086
Practice Address - Fax:805-383-6700
Is Sole Proprietor?:No
Enumeration Date:2013-02-08
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP13234235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist