Provider Demographics
NPI:1770833626
Name:BOGGAN, CALLI
Entity Type:Individual
Prefix:
First Name:CALLI
Middle Name:
Last Name:BOGGAN
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 1:4109 HIGHWAY 98 W
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:MS
Mailing Address - Zip Code:39666-9132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MS
Practice Address - Zip Code:39345-2915
Practice Address - Country:US
Practice Address - Phone:601-683-6644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT2724225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist