Provider Demographics
NPI:1699030833
Name:BOGARIN, EDTNA
Entity Type:Individual
Prefix:
First Name:EDTNA
Middle Name:
Last Name:BOGARIN
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 1:5110 W GOLDLEAF CIR FL 2
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90056-1282
Mailing Address - Country:US
Mailing Address - Phone:213-407-5598
Mailing Address - Fax:
Practice Address - Street 1:5110 W GOLDLEAF CIR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90056-1282
Practice Address - Country:US
Practice Address - Phone:213-407-5598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69143106H00000X
CA171M00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator