Provider Demographics
NPI:1265973978
Name:BOGAN, ANTOINETTE
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:BOGAN
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 1:610 OLD YORK ROAD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046-8406
Mailing Address - Country:US
Mailing Address - Phone:215-820-3235
Mailing Address - Fax:
Practice Address - Street 1:610 OLD YORK RD
Practice Address - Street 2:
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-2837
Practice Address - Country:US
Practice Address - Phone:215-820-3235
Practice Address - Fax:844-605-1833
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-14
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YA0400X
PAPC014544101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional