Provider Demographics
NPI:1144306747
Name:BOGLE, ROBERTA J (LPC)
Entity type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:J
Last Name:BOGLE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:J
Other - Last Name:GLENN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:110 YE OLDE KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-3050
Mailing Address - Country:US
Mailing Address - Phone:843-663-0770
Mailing Address - Fax:843-663-0772
Practice Address - Street 1:110 YE OLDE KINGS HWY
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-3050
Practice Address - Country:US
Practice Address - Phone:843-663-0770
Practice Address - Fax:843-663-0772
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2011-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0008241101Y00000X
SC5005101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor