Provider Demographics
NPI:1407989718
Name:BOGGIO, DAVID BRECK (SW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:BRECK
Last Name:BOGGIO
Suffix:
Gender:M
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4717 HANNETT AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5015
Mailing Address - Country:US
Mailing Address - Phone:505-514-8695
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 3338
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87190-3338
Practice Address - Country:US
Practice Address - Phone:505-255-5099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMZ 85891041S0200X
NMI-43741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMZ 8589Medicaid