Provider Demographics
NPI:1306347356
Name:BOGUCKI, KEITH DAVID (LLMSW)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:DAVID
Last Name:BOGUCKI
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 E NEWELL ST
Mailing Address - Street 2:
Mailing Address - City:WHITE CLOUD
Mailing Address - State:MI
Mailing Address - Zip Code:49349-8795
Mailing Address - Country:US
Mailing Address - Phone:231-689-7330
Mailing Address - Fax:
Practice Address - Street 1:1049 NEWELL
Practice Address - Street 2:P.O. BOX 867
Practice Address - City:WHITE CLOUD
Practice Address - State:MI
Practice Address - Zip Code:49349
Practice Address - Country:US
Practice Address - Phone:231-689-7330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011019151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical