Provider Demographics
NPI:1174333041
Name:BOGAN, CRYSTAL L
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:L
Last Name:BOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 E 40TH ST APT B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-4983
Mailing Address - Country:US
Mailing Address - Phone:773-887-0729
Mailing Address - Fax:
Practice Address - Street 1:438 E 40TH ST APT B
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-4983
Practice Address - Country:US
Practice Address - Phone:773-887-0729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL126200888172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty