Basic Information
| Provider Information | |||||||||
| NPI: | 1841699873 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOOGAART | ||||||||
| FirstName: | CRISTINA | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOLSTAD | ||||||||
| OtherFirstName: | CRISTINA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7310 RITCHIE HWY | ||||||||
| Address2: | 500 | ||||||||
| City: | GLEN BURNIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210613065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107664047 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7310 RITCHIE HWY | ||||||||
| Address2: | 500 | ||||||||
| City: | GLEN BURNIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210613065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107664047 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2014 | ||||||||
| LastUpdateDate: | 03/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 24502 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.