Provider Demographics
NPI:1932427739
Name:BOGULAVSKY, MARK (MA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BOGULAVSKY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6601 BURNS ST
Mailing Address - Street 2:APT 6A
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3948
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6601 BURNS ST
Practice Address - Street 2:APT 6A
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3948
Practice Address - Country:US
Practice Address - Phone:212-734-7719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014283-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist