Provider Demographics
NPI:1235497462
Name:BOGLE, MARY T (PT, DPT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:BOGLE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 33RD RD APT 6D
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11106-4217
Mailing Address - Country:US
Mailing Address - Phone:718-777-3888
Mailing Address - Fax:
Practice Address - Street 1:110 E 42ND ST RM 1504
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017
Practice Address - Country:US
Practice Address - Phone:212-354-2622
Practice Address - Fax:212-354-2752
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034504225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist