Provider Demographics
NPI:1467721233
Name:HOGAN, KIMBERLEY BLYTHE (PHD)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:BLYTHE
Last Name:HOGAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 NORTH MICHIGAN AVE
Mailing Address - Street 2:SUITE 1715
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611
Mailing Address - Country:US
Mailing Address - Phone:312-751-0905
Mailing Address - Fax:
Practice Address - Street 1:625 NORTH MICHIGAN AVE
Practice Address - Street 2:SUITE 1715
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-751-0905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-006459103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist