Provider Demographics
NPI:1013133644
Name:BOGREN, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BOGREN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 EMELINE ST
Mailing Address - Street 2:BLDG K (3RD FLOOR)
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-5320
Mailing Address - Country:US
Mailing Address - Phone:831-454-7435
Mailing Address - Fax:831-454-4747
Practice Address - Street 1:1400 EMELINE ST
Practice Address - Street 2:BLDG K (3RD FLOOR)
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-5320
Practice Address - Country:US
Practice Address - Phone:831-454-7435
Practice Address - Fax:831-454-4747
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAA02820315101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ91892ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#
CAZZZ91892ZMedicaid