Provider Demographics
NPI:1518034859
Name:BOGDAN, ROBERT (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:BOGDAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5802
Mailing Address - Country:US
Mailing Address - Phone:570-899-8171
Mailing Address - Fax:570-718-0421
Practice Address - Street 1:451 3RD AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5802
Practice Address - Country:US
Practice Address - Phone:570-899-8171
Practice Address - Fax:570-718-0421
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0146191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1023217240001Medicaid
PA164498ZDEMedicare PIN