Provider Demographics
NPI:1548405723
Name:BOGUE, KIRSTEN LARA (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:LARA
Last Name:BOGUE
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:LARA
Other - Last Name:MATHESON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1119 HIGH STREET
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701
Mailing Address - Country:US
Mailing Address - Phone:716-307-2557
Mailing Address - Fax:
Practice Address - Street 1:1119 HIGH STREET
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701
Practice Address - Country:US
Practice Address - Phone:716-307-2557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-02
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0122421235Z00000X
PASL009962235Z00000X
NY012242-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02341564Medicaid