Provider Demographics
NPI:1821534389
Name:HOGAN, KRYSTAL DANIELLE
Entity Type:Individual
Prefix:MS
First Name:KRYSTAL
Middle Name:DANIELLE
Last Name:HOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:768 PLEASANT VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:DIAMOND SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95619-9260
Mailing Address - Country:US
Mailing Address - Phone:530-621-6290
Mailing Address - Fax:
Practice Address - Street 1:1660 E ROSEVILLE PKWY
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3988
Practice Address - Country:US
Practice Address - Phone:916-973-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-09
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
CA131495106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional