Provider Demographics
NPI:1336201920
Name:HOGAN, CYNTHIA JANE (LCAS)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:JANE
Last Name:HOGAN
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 E LEXINGTON RD STE B
Mailing Address - Street 2:
Mailing Address - City:MOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27028-2635
Mailing Address - Country:US
Mailing Address - Phone:336-608-2591
Mailing Address - Fax:336-753-6855
Practice Address - Street 1:161 E LEXINGTON RD STE B
Practice Address - Street 2:
Practice Address - City:MOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27028-2635
Practice Address - Country:US
Practice Address - Phone:336-608-2591
Practice Address - Fax:336-753-6855
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC49101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6110513Medicaid