Provider Demographics
NPI:1467460287
Name:HORGAN, MARY J (PSYD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:HORGAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 HIDDEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-2711
Mailing Address - Country:US
Mailing Address - Phone:719-337-3186
Mailing Address - Fax:719-272-6464
Practice Address - Street 1:745 HIDDEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-2711
Practice Address - Country:US
Practice Address - Phone:719-337-3186
Practice Address - Fax:719-272-6464
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2632103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC537308Medicare ID - Type Unspecified