Provider Demographics
NPI:1275838674
Name:BOGART, ODETTE DENISE (MS)
Entity Type:Individual
Prefix:
First Name:ODETTE
Middle Name:DENISE
Last Name:BOGART
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5716 WOLF LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33875-8055
Mailing Address - Country:US
Mailing Address - Phone:863-446-3369
Mailing Address - Fax:
Practice Address - Street 1:121 N 2ND ST
Practice Address - Street 2:SUITE 301
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4435
Practice Address - Country:US
Practice Address - Phone:772-595-3773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-14
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT1625106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist