Provider Demographics
NPI:1528414026
Name:BROGDON, MARY GRACE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:GRACE
Last Name:BROGDON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 GARDEN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97403-1962
Mailing Address - Country:US
Mailing Address - Phone:541-870-3142
Mailing Address - Fax:
Practice Address - Street 1:1907 GARDEN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97403-1962
Practice Address - Country:US
Practice Address - Phone:541-870-3142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-13
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR47641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical