Provider Demographics
NPI:1952769192
Name:HOGAN, GOLDA IVASHKOV (BS)
Entity Type:Individual
Prefix:
First Name:GOLDA
Middle Name:IVASHKOV
Last Name:HOGAN
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 N FOGG ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110-5143
Mailing Address - Country:US
Mailing Address - Phone:702-408-0148
Mailing Address - Fax:
Practice Address - Street 1:6048 S DURANGO DR STE 115
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-1781
Practice Address - Country:US
Practice Address - Phone:702-815-1550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-02
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV07730-I101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)