Provider Demographics
NPI:1437328366
Name:BOGARD, STAN (IMF)
Entity Type:Individual
Prefix:
First Name:STAN
Middle Name:
Last Name:BOGARD
Suffix:
Gender:M
Credentials:IMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2535 KETTNER BLVD
Mailing Address - Street 2:SUITE 1A4
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-1250
Mailing Address - Country:US
Mailing Address - Phone:619-615-0701
Mailing Address - Fax:619-615-0705
Practice Address - Street 1:2535 KETTNER BLVD
Practice Address - Street 2:SUITE 1A4
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-1250
Practice Address - Country:US
Practice Address - Phone:619-615-0701
Practice Address - Fax:619-615-0705
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50213104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker