Provider Demographics
NPI:1821484585
Name:BOMGARDNER, DOROTHY
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:
Last Name:BOMGARDNER
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 1:8262 SAND ROCK RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON
Mailing Address - State:PA
Mailing Address - Zip Code:16652-3685
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 E CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-5215
Practice Address - Country:US
Practice Address - Phone:814-943-0414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC000072101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor