Provider Demographics
NPI:1134913999
Name:BOGGS, GRACIE MARIE
Entity type:Individual
Prefix:
First Name:GRACIE
Middle Name:MARIE
Last Name:BOGGS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:GRACIE
Other - Middle Name:MARIE
Other - Last Name:BULLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4321 41ST AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NE
Mailing Address - Zip Code:68601-2131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2740 N CLARKSON ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-7702
Practice Address - Country:US
Practice Address - Phone:402-562-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-07
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE14333101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health