Provider Demographics
NPI:1407512353
Name:GROGAN, IMANI WANGARE (LMSW)
Entity Type:Individual
Prefix:
First Name:IMANI
Middle Name:WANGARE
Last Name:GROGAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12337 JONES RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-4800
Mailing Address - Country:US
Mailing Address - Phone:210-380-9389
Mailing Address - Fax:
Practice Address - Street 1:2602 DIVING DUCK CT
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77396-4857
Practice Address - Country:US
Practice Address - Phone:210-380-9389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX669791041C0700X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical