Provider Demographics
NPI:1336640879
Name:DALE- HOGAN, NICOLE (MLADC, LICSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DALE- HOGAN
Suffix:
Gender:F
Credentials:MLADC, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 GONIC RD STE 2A
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03839-5689
Mailing Address - Country:US
Mailing Address - Phone:603-332-8000
Mailing Address - Fax:603-601-4476
Practice Address - Street 1:323 GONIC RD STE 2A
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03839-5689
Practice Address - Country:US
Practice Address - Phone:603-332-8000
Practice Address - Fax:603-601-4476
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0566101YA0400X
1041C0700X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3121377Medicaid