Provider Demographics
NPI:1053291237
Name:VOGT, TINA M
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:VOGT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 FAWN MEADOWS LN
Mailing Address - Street 2:PO BOX 41
Mailing Address - City:KILA
Mailing Address - State:MT
Mailing Address - Zip Code:59920
Mailing Address - Country:US
Mailing Address - Phone:808-755-5225
Mailing Address - Fax:
Practice Address - Street 1:21 FAWN MEADOW LN
Practice Address - Street 2:
Practice Address - City:KILA
Practice Address - State:MT
Practice Address - Zip Code:59920-8565
Practice Address - Country:US
Practice Address - Phone:808-755-5225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-06
Last Update Date:2025-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTC1159918171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach