Basic Information
| Provider Information | |||||||||
| NPI: | 1174174825 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOGUS | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 375 ALLENS AVE | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029055010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014440400 | ||||||||
| FaxNumber: | 4014440468 | ||||||||
| Practice Location | |||||||||
| Address1: | 239 CRANSTON ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029072406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014440580 | ||||||||
| FaxNumber: | 4014440428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2019 | ||||||||
| LastUpdateDate: | 08/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | ISW02990 | RI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.