Provider Demographics
NPI:1619713773
Name:MOGG, NATHANIEL ROBERT
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:ROBERT
Last Name:MOGG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:NATE
Other - Middle Name:ROBERT
Other - Last Name:MOGG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5232 E BROADWAY RD LOT 336
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-7908
Mailing Address - Country:US
Mailing Address - Phone:989-944-9742
Mailing Address - Fax:
Practice Address - Street 1:2850 W CHEESMAN RD
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-8757
Practice Address - Country:US
Practice Address - Phone:989-285-1692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI200622745249106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician