Provider Demographics
NPI:1851916878
Name:BOGOLIN, OLIVIA MARIE (ATC)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:MARIE
Last Name:BOGOLIN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 TIMBER TRACE XING
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-2124
Mailing Address - Country:US
Mailing Address - Phone:314-482-3886
Mailing Address - Fax:
Practice Address - Street 1:111 TIMBER TRACE XING
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-2124
Practice Address - Country:US
Practice Address - Phone:314-482-3886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170435892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer