Provider Demographics
NPI:1740201870
Name:HOGAN, BRENTLY SHANE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BRENTLY
Middle Name:SHANE
Last Name:HOGAN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1123 FORSYTHE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-4307
Mailing Address - Country:US
Mailing Address - Phone:318-322-9980
Mailing Address - Fax:318-322-9946
Practice Address - Street 1:1123 FORSYTHE AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-4307
Practice Address - Country:US
Practice Address - Phone:318-322-9980
Practice Address - Fax:318-322-9946
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06610225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CR37Medicare ID - Type UnspecifiedGROUP PHYSICAL THERAPY #