Provider Demographics
NPI:1518718352
Name:BOGGAN, DE'ASHA M
Entity Type:Individual
Prefix:
First Name:DE'ASHA
Middle Name:M
Last Name:BOGGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3476 CROSS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-3655
Mailing Address - Country:US
Mailing Address - Phone:334-233-6195
Mailing Address - Fax:
Practice Address - Street 1:3476 CROSS CREEK DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-3655
Practice Address - Country:US
Practice Address - Phone:334-233-6195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-29
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician