Provider Demographics
NPI:1679984660
Name:BOGOMOLNY, MICHELLE RAE (PT)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:RAE
Last Name:BOGOMOLNY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 WARRENSVILLE CENTER ROAD
Mailing Address - Street 2:BUILDING A/DRIVEWAY 1
Mailing Address - City:WARRENSVILLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122
Mailing Address - Country:US
Mailing Address - Phone:216-491-6180
Mailing Address - Fax:
Practice Address - Street 1:4110 WARRENSVILLE CENTER RD
Practice Address - Street 2:BUILDING A/DRIVEWAY 1
Practice Address - City:WARRENSVILLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44122-7024
Practice Address - Country:US
Practice Address - Phone:216-491-6180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH004649225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist