Provider Demographics
NPI:1801253919
Name:HOGAN, EBONY (MED, CRC, CFLE)
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:HOGAN
Suffix:
Gender:F
Credentials:MED, CRC, CFLE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23420 LORI DR
Mailing Address - Street 2:
Mailing Address - City:BEDFORD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44146-2353
Mailing Address - Country:US
Mailing Address - Phone:440-317-0563
Mailing Address - Fax:
Practice Address - Street 1:23420 LORI DR
Practice Address - Street 2:
Practice Address - City:BEDFORD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44146-2353
Practice Address - Country:US
Practice Address - Phone:440-317-0563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0149248Medicaid