Basic Information
| Provider Information | |||||||||
| NPI: | 1407037625 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOGARD | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | GRACE | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11762 DE PALMA RD | ||||||||
| Address2: | SUITE 1C, PMB 57 | ||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928834010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512581938 | ||||||||
| FaxNumber: | 9513416404 | ||||||||
| Practice Location | |||||||||
| Address1: | 3625 14TH ST | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925013815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519551540 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2007 | ||||||||
| LastUpdateDate: | 08/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 163W00000X | 450753 | CA | Y | Nursing Service Providers | Registered Nurse |
No ID Information.