Provider Demographics
NPI:1164075552
Name:BOGART, CAROLYN (PT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:BOGART
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 WASHINGTON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-6525
Mailing Address - Country:US
Mailing Address - Phone:262-321-6000
Mailing Address - Fax:
Practice Address - Street 1:7300 WASHINGTON AVE STE B
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-6525
Practice Address - Country:US
Practice Address - Phone:262-321-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070024731225100000X
WI14602225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100198658Medicaid