Provider Demographics
NPI:1568071785
Name:BOMGARDNER, GEORGIA DARE (PHD)
Entity Type:Individual
Prefix:DR
First Name:GEORGIA
Middle Name:DARE
Last Name:BOMGARDNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:793 E WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18017-6043
Mailing Address - Country:US
Mailing Address - Phone:901-230-2919
Mailing Address - Fax:
Practice Address - Street 1:1 E BROAD ST STE 510
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18018-5964
Practice Address - Country:US
Practice Address - Phone:610-865-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS019058103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist