Provider Demographics
NPI:1932115847
Name:KOGAN, SANDRA LEE (PH D)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:KOGAN
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 PROGRESS WAY
Mailing Address - Street 2:#101
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784
Mailing Address - Country:US
Mailing Address - Phone:410-549-5181
Mailing Address - Fax:410-549-5182
Practice Address - Street 1:1380 PROGRESS WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784
Practice Address - Country:US
Practice Address - Phone:410-549-5181
Practice Address - Fax:410-549-5182
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03742103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD669LH926Medicare ID - Type Unspecified