Basic Information
| Provider Information | |||||||||
| NPI: | 1063051217 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOGER | ||||||||
| FirstName: | AYESHA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | ALC, MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 312 GWINNETT PL | ||||||||
| Address2: | |||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363014933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347903600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 700 E COTTONWOOD RD | ||||||||
| Address2: | |||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363013644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347947373 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2020 | ||||||||
| LastUpdateDate: | 01/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | C3349A | AL | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.