Provider Demographics
NPI:1891514824
Name:VAN DEN BOOGAARD, ELLIS PETRONELLA (MS ED, MA)
Entity type:Individual
Prefix:MRS
First Name:ELLIS
Middle Name:PETRONELLA
Last Name:VAN DEN BOOGAARD
Suffix:
Gender:F
Credentials:MS ED, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92058-1201
Mailing Address - Country:US
Mailing Address - Phone:760-072-1170
Mailing Address - Fax:
Practice Address - Street 1:5335 CALLE VIS
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-1920
Practice Address - Country:US
Practice Address - Phone:858-882-7860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19-109521106S00000X
CA23-294299106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician