Provider Demographics
NPI:1760857270
Name:BOGARD, DOROTHY RUTH
Entity Type:Individual
Prefix:MRS
First Name:DOROTHY
Middle Name:RUTH
Last Name:BOGARD
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 1:1430 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1623
Mailing Address - Country:US
Mailing Address - Phone:781-647-5327
Mailing Address - Fax:
Practice Address - Street 1:1430 MAIN ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1623
Practice Address - Country:US
Practice Address - Phone:781-647-5327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA042104356OtherEIN