Provider Demographics
NPI:1003901398
Name:HOGAN, DEIRDRE G (LCSW)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:G
Last Name:HOGAN
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 1:153 US ROUTE 1
Mailing Address - Street 2:SUITE 26, BOX 10
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9052
Mailing Address - Country:US
Mailing Address - Phone:207-329-9621
Mailing Address - Fax:207-883-2721
Practice Address - Street 1:153 US ROUTE 1
Practice Address - Street 2:SUITE 26, BOX 10
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-9052
Practice Address - Country:US
Practice Address - Phone:207-329-9621
Practice Address - Fax:207-883-2721
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC6912101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431517499Medicaid
ME431517499Medicaid
MEMM3722Medicare PIN