Basic Information
Provider Information | |||||||||
NPI: | 1568706430 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VOGT | ||||||||
FirstName: | JAMIE | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PTA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KNAPP | ||||||||
OtherFirstName: | JAMIE | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PTA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1571 CANANDAIGUA RD | ||||||||
Address2: |   | ||||||||
City: | MACEDON | ||||||||
State: | NY | ||||||||
PostalCode: | 145029742 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5859442851 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 41 COLEBROOK DR | ||||||||
Address2: |   | ||||||||
City: | ROCHESTER | ||||||||
State: | NY | ||||||||
PostalCode: | 146172211 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5854674567 | ||||||||
FaxNumber: | 5854676973 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2012 | ||||||||
LastUpdateDate: | 11/16/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 006933-1 | NY | Y |   | Other Service Providers | Specialist |   |
No ID Information.