Provider Demographics
NPI:1043997810
Name:HOGAN, SCOTT M
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:M
Last Name:HOGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 E HAMILTON RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-7574
Mailing Address - Country:US
Mailing Address - Phone:309-828-5231
Mailing Address - Fax:
Practice Address - Street 1:105 E HAMILTON RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-7574
Practice Address - Country:US
Practice Address - Phone:309-828-5231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183097103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool