Basic Information
| Provider Information | |||||||||
| NPI: | 1104200781 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOGAN | ||||||||
| FirstName: | MARIAN | ||||||||
| MiddleName: | JUSTINE SULLIVAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SULLIVAN | ||||||||
| OtherFirstName: | MARIAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 18217 HALE AVE | ||||||||
| Address2: | |||||||||
| City: | MORGAN HILL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950373550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4084658280 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 18217 HALE AVE | ||||||||
| Address2: | |||||||||
| City: | MORGAN HILL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950373550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4084658280 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2015 | ||||||||
| LastUpdateDate: | 08/25/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 64461 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 115615 | MA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.