Provider Demographics
NPI:1073004123
Name:BOGART, MACKENZIE M (OTR)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:M
Last Name:BOGART
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:M
Other - Last Name:CONKLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 230
Mailing Address - Street 2:
Mailing Address - City:HUGUENOT
Mailing Address - State:NY
Mailing Address - Zip Code:12746-0230
Mailing Address - Country:US
Mailing Address - Phone:845-926-8826
Mailing Address - Fax:
Practice Address - Street 1:41 COUNTY RD 49
Practice Address - Street 2:
Practice Address - City:SLATE HILL
Practice Address - State:NY
Practice Address - Zip Code:10973
Practice Address - Country:US
Practice Address - Phone:845-697-5064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022547225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist