Provider Demographics
NPI:1104259027
Name:BOGUCKI, WALTER ALBERT (CADC)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:ALBERT
Last Name:BOGUCKI
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 E FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-5823
Mailing Address - Country:US
Mailing Address - Phone:208-463-0118
Mailing Address - Fax:208-463-1507
Practice Address - Street 1:508 E FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5823
Practice Address - Country:US
Practice Address - Phone:208-463-0118
Practice Address - Fax:208-463-1507
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID10067101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)