Provider Demographics
NPI:1285666479
Name:BROGAN, MARY KATHLEEN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:BROGAN
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 1:3111 W DR MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607
Mailing Address - Country:US
Mailing Address - Phone:813-205-3870
Mailing Address - Fax:813-350-7801
Practice Address - Street 1:3111 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607
Practice Address - Country:US
Practice Address - Phone:813-205-3870
Practice Address - Fax:813-350-7801
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW39371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
2142050OtherCIGNA
Z032BOtherBLUE CROSS BLUE SHIELD
Z032BOtherBLUE CROSS BLUE SHIELD