Provider Demographics
NPI:1295960003
Name:BOGUMILL, MARY K (PHD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:BOGUMILL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:K
Other - Last Name:BOGUMILL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:2475 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-4928
Mailing Address - Country:US
Mailing Address - Phone:406-444-2288
Mailing Address - Fax:406-444-2163
Practice Address - Street 1:2475 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-4928
Practice Address - Country:US
Practice Address - Phone:406-444-2288
Practice Address - Fax:406-444-2163
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-22
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist