Provider Demographics
NPI:1942312046
Name:HOGAN, GLENN (PH D)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:HOGAN
Suffix:
Gender:M
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 1:11215 OAK LEAF DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-1317
Mailing Address - Country:US
Mailing Address - Phone:301-593-1315
Mailing Address - Fax:301-681-4699
Practice Address - Street 1:11215 OAK LEAF DR
Practice Address - Street 2:SUITE 108
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-1317
Practice Address - Country:US
Practice Address - Phone:301-593-1315
Practice Address - Fax:301-681-4699
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02721103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD632ML070Medicare ID - Type Unspecified
Q40202Medicare UPIN