Provider Demographics
NPI:1710367305
Name:BOGGS, KARIN DENISE (LCDC)
Entity Type:Individual
Prefix:
First Name:KARIN
Middle Name:DENISE
Last Name:BOGGS
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 S VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-4344
Mailing Address - Country:US
Mailing Address - Phone:254-965-5515
Mailing Address - Fax:254-965-7416
Practice Address - Street 1:4113A HIGHWAY 180 EAST
Practice Address - Street 2:SUITE C
Practice Address - City:MINERAL WELLS
Practice Address - State:TX
Practice Address - Zip Code:76067
Practice Address - Country:US
Practice Address - Phone:940-325-3402
Practice Address - Fax:940-325-3408
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12289101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148686201Medicaid