Provider Demographics
NPI:1659377182
Name:HOGUE, MARK ALLEN (PSYD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:HOGUE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E 2ND ST
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1537
Mailing Address - Country:US
Mailing Address - Phone:814-452-8300
Mailing Address - Fax:814-452-8308
Practice Address - Street 1:120 E 2ND ST
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1537
Practice Address - Country:US
Practice Address - Phone:814-452-8300
Practice Address - Fax:814-452-8308
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-004347-L103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA620006097OtherRAILROAD MEDICARE IND#
PA7368785Medicaid
PA620006097OtherRAILROAD MEDICARE IND#
PAHO151025Medicare ID - Type Unspecified