Provider Demographics
NPI:1497169841
Name:BOGDON, ELIZABETH MARY (MA)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:MARY
Last Name:BOGDON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:BETH
Other - Middle Name:MARY
Other - Last Name:BOGDON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:3406 N WILLIS BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-7264
Mailing Address - Country:US
Mailing Address - Phone:971-284-7313
Mailing Address - Fax:
Practice Address - Street 1:2225 NE MLK JR BLVD
Practice Address - Street 2:STE 207
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3727
Practice Address - Country:US
Practice Address - Phone:971-284-7313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2016-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4160101YM0800X
WACG60460126101YM0800X
WAMC60480487101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health