Provider Demographics
NPI:1144368648
Name:VOGT, MARY JILL (LCSW,BCD)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:JILL
Last Name:VOGT
Suffix:
Gender:F
Credentials:LCSW,BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3351 EASTBROOK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5745
Mailing Address - Country:US
Mailing Address - Phone:970-482-3121
Mailing Address - Fax:970-419-3185
Practice Address - Street 1:1217 E ELIZABETH ST
Practice Address - Street 2:BUILDING 6
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4040
Practice Address - Country:US
Practice Address - Phone:970-495-3453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9860371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO30570549Medicaid
COC86396Medicare ID - Type Unspecified