Basic Information
| Provider Information | |||||||||
| NPI: | 1710367305 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOGGS | ||||||||
| FirstName: | KARIN | ||||||||
| MiddleName: | DENISE | ||||||||
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| Credential: | LCDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 239 S VIRGINIA ST | ||||||||
| Address2: | |||||||||
| City: | STEPHENVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764014344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2549655515 | ||||||||
| FaxNumber: | 2549657416 | ||||||||
| Practice Location | |||||||||
| Address1: | 4113A HIGHWAY 180 EAST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MINERAL WELLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403253402 | ||||||||
| FaxNumber: | 9403253408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2015 | ||||||||
| LastUpdateDate: | 06/09/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 12289 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 148686201 | 05 | TX | MEDICAID |