Provider Demographics
NPI:1770585416
Name:BOGET, JOHN M (LCSW)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:M
Last Name:BOGET
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3008
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3008
Mailing Address - Country:US
Mailing Address - Phone:618-457-0450
Mailing Address - Fax:618-457-7329
Practice Address - Street 1:1250 CEDAR CT
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5334
Practice Address - Country:US
Practice Address - Phone:618-351-1213
Practice Address - Fax:618-351-1905
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0052101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149005210Medicaid
IL149005210Medicaid
P77334Medicare UPIN