Provider Demographics
NPI:1265163315
Name:BOGRETTE, RYAN EDMUND (DPT)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:EDMUND
Last Name:BOGRETTE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:379 W BROADWAY
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-2217
Practice Address - Country:US
Practice Address - Phone:617-968-3999
Practice Address - Fax:617-752-4127
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA26241225100000X
CT225100000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program