Provider Demographics
NPI:1699366526
Name:BOGNACKI, CORINNE (LMT)
Entity Type:Individual
Prefix:
First Name:CORINNE
Middle Name:
Last Name:BOGNACKI
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 W LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-2261
Mailing Address - Country:US
Mailing Address - Phone:310-804-6562
Mailing Address - Fax:
Practice Address - Street 1:1520 W LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-2261
Practice Address - Country:US
Practice Address - Phone:310-804-6562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT18456225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist