Provider Demographics
NPI:1649327248
Name:BOGGESS, KATHLEEN WEIHER (LCSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:WEIHER
Last Name:BOGGESS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 HARMON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5641
Mailing Address - Country:US
Mailing Address - Phone:912-435-6965
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVE
Practice Address - Street 2:
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314
Practice Address - Country:US
Practice Address - Phone:912-435-6965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2018-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9926291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO532811Medicaid
COC801523Medicare ID - Type Unspecified