Provider Demographics
NPI:1407037625
Name:BOGARD, VICTORIA GRACE (PMHNP)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:GRACE
Last Name:BOGARD
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11762 DE PALMA RD
Mailing Address - Street 2:SUITE 1C, PMB 57
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-4010
Mailing Address - Country:US
Mailing Address - Phone:951-258-1938
Mailing Address - Fax:951-341-6404
Practice Address - Street 1:3625 14TH ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3815
Practice Address - Country:US
Practice Address - Phone:951-955-1540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA450753163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health