Provider Demographics
NPI:1679628648
Name:HOGAN, KERRY L (PHD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:L
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 1:3973B MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-1403
Mailing Address - Country:US
Mailing Address - Phone:910-763-0699
Mailing Address - Fax:910-763-0489
Practice Address - Street 1:3973B MARKET ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-1403
Practice Address - Country:US
Practice Address - Phone:910-763-0699
Practice Address - Fax:910-763-0489
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2968103TC0700X, 103TC2200X, 103TM1800X, 103TP2701X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000934Medicaid