Provider Demographics
NPI:1831151836
Name:VOGT, PHYLLIS H (LCSWR)
Entity type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:H
Last Name:VOGT
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 WASHINGTON ST
Mailing Address - Street 2:MANAGED CARE DEPARTMENT
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1711
Mailing Address - Country:US
Mailing Address - Phone:716-856-4494
Mailing Address - Fax:716-842-1277
Practice Address - Street 1:1089 KINKEAD AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:N TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-2840
Practice Address - Country:US
Practice Address - Phone:716-692-1440
Practice Address - Fax:716-692-1277
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00032528104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP14961Medicare UPIN