Provider Demographics
NPI:1124193180
Name:BOGSTAD, KEVIN RICHARD (MA LPC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:RICHARD
Last Name:BOGSTAD
Suffix:
Gender:M
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 ELKTON DR STE 300
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-3597
Mailing Address - Country:US
Mailing Address - Phone:951-837-3722
Mailing Address - Fax:
Practice Address - Street 1:1115 ELKTON DR STE 300
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-3597
Practice Address - Country:US
Practice Address - Phone:951-837-3722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
COLPC.0014136103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health