Basic Information
| Provider Information | |||||||||
| NPI: | 1912155045 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOGG | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MED,CAC,LPC,CCDP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 PINEWOOD AVE. | ||||||||
| Address2: | |||||||||
| City: | LITITZ | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176266811 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3030 CHESTNUT ST. | ||||||||
| Address2: | LEBANON TREATMENT CENTER | ||||||||
| City: | LEBANON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172738000 | ||||||||
| FaxNumber: | 7172738244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2008 | ||||||||
| LastUpdateDate: | 09/03/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | PC000649 | PA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.