Provider Demographics
NPI:1760995500
Name:MOGAN, ANTHONY MICHAEL (CDCA,QMHS)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:MICHAEL
Last Name:MOGAN
Suffix:
Gender:M
Credentials:CDCA,QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 226
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-0226
Mailing Address - Country:US
Mailing Address - Phone:740-947-6727
Mailing Address - Fax:
Practice Address - Street 1:14574 US HIGHWAY 23
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-9373
Practice Address - Country:US
Practice Address - Phone:740-912-9126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH101YA0400XMedicaid