Provider Demographics
NPI:1992438840
Name:BOGACKI, LISA JOAN (PT, MPH, ESMT, CCMT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:JOAN
Last Name:BOGACKI
Suffix:
Gender:F
Credentials:PT, MPH, ESMT, CCMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 FRIENDSHIP DR
Mailing Address - Street 2:
Mailing Address - City:FLEETWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19522-1902
Mailing Address - Country:US
Mailing Address - Phone:610-823-3518
Mailing Address - Fax:610-944-0383
Practice Address - Street 1:403 FRIENDSHIP DR
Practice Address - Street 2:
Practice Address - City:FLEETWOOD
Practice Address - State:PA
Practice Address - Zip Code:19522-1902
Practice Address - Country:US
Practice Address - Phone:610-823-3518
Practice Address - Fax:610-933-0383
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT002931E225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist