Provider Demographics
NPI:1770788382
Name:BOGDON, MICHAEL JOSEPH (LISW)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:BOGDON
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1715
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44003-1715
Mailing Address - Country:US
Mailing Address - Phone:440-293-3305
Mailing Address - Fax:
Practice Address - Street 1:60 WEST ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:OH
Practice Address - Zip Code:44041-9723
Practice Address - Country:US
Practice Address - Phone:440-293-3305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI00076851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical