Provider Demographics
NPI:1386195782
Name:BOGLE, LAUREL (PTA)
Entity Type:Individual
Prefix:MRS
First Name:LAUREL
Middle Name:
Last Name:BOGLE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1098 BLUE SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:SMITHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37166-6075
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:825 FISHER AVE
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37166-2140
Practice Address - Country:US
Practice Address - Phone:615-597-4182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3206261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy