Provider Demographics
NPI:1336889401
Name:CAMPOS BOGUTSKAYA, ANIA
Entity Type:Individual
Prefix:
First Name:ANIA
Middle Name:
Last Name:CAMPOS BOGUTSKAYA
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 1:1210 SE 46TH LN
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-8601
Mailing Address - Country:US
Mailing Address - Phone:888-996-4694
Mailing Address - Fax:
Practice Address - Street 1:1210 SE 46TH LN
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-8601
Practice Address - Country:US
Practice Address - Phone:888-996-4694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician